Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JANET REHNQUIST 

INSPECTOR GENERAL 

FEBRUARY 2003 

OEI-06-99-00300 

Nursing Home Medical Directors 

Survey 
OFFICE OF INSPECTOR GENERAL

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 

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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, 

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community, and issues fraud alerts and other industry guidance. 
EXECUTIVE SUMMARY 

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 patient’s drug regimen (69 percent), a patient’s 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 facility’s 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 purposivelysampled 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 director’s role. 

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Nursing Home Medical Directors iii OEI-06-99-00300 
TABLE OF CONTENTS 

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 ................ 18

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
INTRODUCTION 

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 wellbeing. 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 patient’s need for nursing home care and 

routinely provides the clinical response to a patient’s 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 director’s 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 director’s 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 home’s 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 state’s 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 state’s 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 hospitalbased12 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 director’s 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 director’s 

role from three perspectives: 

1) Expectation of the nursing home (e.g., required by the nursing home) that the function is the 

medical director’s 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 director’s leadership in several 

key areas and other questions intended to provide supplemental information about the medical 

director’s 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 director’s 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 President’s Council on Integrity and Efficiency. 

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Nursing Home Medical Directors 5 OEI-06-99-00300 
SURVEY RESPONSE 

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 

Specific and Related Functions 

Nursing Homes Expect 

of Medical Directors 

Medical Directors 

Should Perform 

Review and revise existing medical and clinical 

policies 

90% 97% 

Encourage quality of care, regardless of patient case 

mix 

88% 92% 

Review and analyze quality indicators for potential 

areas of concern 

86% 91% 

Quality improvement planning, implementing, and/or 

follow-up 

84% 93% 

Development of medical care policies and 

procedures 

81% 92% 

Confirm patient’s problems identified by unit nurses 

are adequately addressed 

73% 83% 

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 – patient’s problems identified by unit nurses are adequately addressed 

(73 percent) and serving as the patient’s medical advocate (64 percent). The latter refers to 

ensuring that the patient’s 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 facility’s expectation to have a physician 

on the facility’s 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 physician’s 

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 

Specific and Related Functions 

Nursing Homes Expect of 

Medical Directors 

Medical Directors 

Should Perform 

Intervene with attending physician when concerns are 

raised about his/her patient's care 

92% 97% 

Review consultant pharmacists’ drug regimen reports 90% 93% 

Interact with Nurses: 

Provide ongoing medical advice and guidance to 

nurses 

Meet routinely with nurses to discuss patient care 

issues 

86% 

78% 

94% 

88% 

Perform attending physician duties 72% 83% 

Participate in the planning of patient care by ensuring the 

appropriateness of services and treatments 

69% 83% 

Monitor for appropriate patient care by attending 

physicians 

68% 85% 

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 

Specific and Related Functions 

Nursing Homes Expect of 

Medical Directors 

Medical Directors 

Should Perform 

Verify appropriateness of a patient’s drug regimen, 

ensure that drugs are: 

-- appropriately prescribed 

-- necessary 

69% 

69% 

80% 

75% 

Ensure patients' end of life decisions are honored 69% 80% 

Verify appropriate medical response to drug regimen 

review concerns 

68% 80% 

Confirm appropriate restraint usage 65% 77% 

Ensure cognitive patients' rights to refuse medications 60% 76% 

Support patients' direct involvement in care planning, if 

mentally able 

60% 70% 

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 patient’s 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 

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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 

Specific and Related Functions 

Nursing Homes Expect of 

Medical Directors 

Medical Directors 

Should Perform 

Provide medical expertise for facility when necessary to 

respond to regulatory agency survey concerns 

94% 96% 

Serve as liaison between medical staff, nursing staff, 

and administration 

84% 88% 

Keep current with regulatory and medical treatment 

changes 

83% 92% 

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 

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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 patient’s 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%) 

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Nursing Home Medical Directors 13 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 

Specific Functions 

Nursing Homes 

Expect of Medical 

Directors 

Medical Directors 

Should Perform 

Patient Services - Staffing 

Ensure sufficient staffing required to meet all patients’ 

needs 

Ensure sufficient nursing coverage for all shifts 

Ensure sufficient nurse aide coverage for all shifts 

9% 

3% 

3% 

27% 

13% 

11% 

Patient Services - Appropriate Care 

Ensure sufficient, appropriate supplies for each patient’s 

needs 

17% 25% 

Administration - Physical Environment 

Verify facility’s sanitary storage, preparation, and service 

of food 

Confirm facility’s adequate and comfortable lighting 

levels for patients 

12% 

11% 

22% 

22% 

Residents’ Rights 

Ensure at admission availability of patients’ prior 

medical records and advance directives 

28% 39% 

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. 

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Nursing Home Medical Directors 14 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 

Specific Functions 

Nursing Homes 

Expect of Medical 

Directors 

Medical Directors 

Should Perform 

Patient Services – Direct Care 

Perform patient rounds, which include direct contact 

with patients 

51% 62% 

Actively treat or supervise the treatment of patients’ 

acute illnesses 

50% 54% 

Perform comprehensive patient assessments 40% 48% 

Patient Services – Appropriate Care 

Monitor care performed by nurse aides 33% 46% 

Develop performance indicators for attending 

physicians 

31% 60% 

Lead or chair the development of patient healthcare 

plans for all patients 

27% 47% 

Meet routinely with nurse aides to discuss patient care 24% 40% 

Administration (Training) 

Teach attending physicians about state and federal 

regulations 

Educate healthcare staff on new policies and 

procedures 

Promote training related to all staffs’ functional 

requirements 

38% 

37% 

36% 

57% 

51% 

45% 

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 patient’s 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 

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Nursing Home Medical Directors 15 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 physician’s 

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 home’s 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, 

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Nursing Home Medical Directors 16 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 

2 to 3 times weekly 

1 time weekly 

1 time every 2 weeks 

1 time monthly 

1 time every 2 months 

variable schedule 

7% 

23% 

34% 

10% 

11% 

7% 

9% 

Number of hours per week they spend in the facility: 

less than 1 to 4 hours 

5 to 8 hours 

9 to more than 15 hours 

72% 

14% 

14% 

Part of their overall medical practice devoted to their 

medical director role: 

1 to 10 percent 

11 to 33 percent 

more than 33 percent 

70% 

23% 

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 

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Nursing Home Medical Directors 17 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. 

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Nursing Home Medical Directors 18 OEI-06-99-00300 
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 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 

director’s role. 

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Nursing Home Medical Directors 19 OEI-06-99-00300
ENDNOTES 

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 Court’s 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). 

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Nursing Home Medical Directors 20 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 hospital’s 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. 

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Nursing Home Medical Directors 21 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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Nursing Home Medical Directors 22 OEI-06-99-00300 
APPENDIX A 

SUMMARY OF PHYSICIAN-RELATED SURVEY 

AND CERTIFICATION NURSING HOME REGULATIONS (1) 

General Purpose of 

Regulation(2) 

Physicians should Ensure 

for Patients and Facility 

Code of 

Federal 

Regulations 

(42 CFR 

Citation) 

Centers 

for 

Medicare & 

Medicaid 

Services 

Deficiency 

Tags 

Intent of Regulation for Physicians 

(Attending or Medical Director) 

Resident Rights 

Right to a Dignified Existence 

Right to be Informed 

(understandability related to the 

patient’s needs) 

Right to Refuse Treatment 

Right to be Informed concerning 

costs, legal rights, and name, 

speciality, and way of contacting the 

physician responsible for his/her care 

Right to Choose attending physician 

Participate in Planning Care and 

Treatment (and changes) 

Right to Self-Administer Drugs 

Right to be Free from Restraints 

Right to be Free from Abuse 

Staff Treatment of Residents 

483.10 

483.13 

150 

154 

155 

156 

163 

280 

176 

221, 222 

223 

224 

Lays the foundation for resident’s rights 

requirements and ensures promotion of the 

exercise of these rights by patients’. 

Resident Assessment and 

Comprehensive Care Plans, 

including Review and Frequency 

483.20(b)(1)-

483.20(b)(2)(ixiii), 

483.20(b)(4) 

272-280, 

285 

Monitor physician participation in assessment 

and care planning, particularly as related to the 

state-specified Resident Assessment Instrument, 

including both the Minimum Data Set and the 

utilization guidelines with Resident Assessment 

Protocols. This includes ensuring that the 

assessment is accurate and reflects the patient’s 

current status, to ensure each assessment is 

prepared by those qualified to assess care based on 

knowledge about the patient’s status and needs. 

Quality of Care 483.25 309-331 

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 

patient’s 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. 

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Nursing Home Medical Directors 23 OEI-06-99-00300 
General Purpose of 

Regulation(2) 

Physicians should Ensure 

for Patients and Facility 

Code of 

Federal 

Regulations 

(42 CFR 

Citation) 

Centers 

for 

Medicare & 

Medicaid 

Services 

Deficiency 

Tags 

Intent of Regulation for Physicians 

(Attending or Medical Director) 

Drug Regimen Review 483.6 428 

Ensure that each patient has a review at least 

monthly by a licenced pharmacist with the 

understanding that the review may have to occur 

more frequently, depending on the patient’s 

condition and drugs prescribed. 

Infection Control 483.65 441 

Ensure that a facility infection-control program 

effectively investigates, controls, and prevents 

infections. 

Medical Director 

Relates to 483.60 

483.75 

483.75(i) 

483.75(i)(2)(i) 

483.75(o) 

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 

privileges and practices, and responsibilities of 

non-physician health-care workers. Implement 

resident care policies regarding accidents and 

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 

overall clinical care of patients to ensure adequacy 

of patient care services. 

The medical director may be the designated 

physician serving on this committee. 

Clinical Records 483.75(l) 514 

Ensure accurate, complete, and organized clinical 

information concerning each patient and ready 

access to such information. To ensure safety and 

confidentiality of patient records. 

Quality Assessment 

and Assurance 

483.75(o) 520 

Ensure the establishment of quality assurance 

committees to identify and address quality issues 

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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Nursing Home Medical Directors 24 OEI-06-99-00300 
APPENDIX B 

SEVEN SAMPLE STATES - SELECTED INFORMATION(1), (2) 

States 

1999 

Certified 

NFs(3) as % 

of Total 

Certified 

NFs 

1999 

Home Beds as 

% of Total 

State 

Medicare/ 

Medicaid 

Recipients(4) 

Certified 

Beds as 

% of 

Total 

Certified 

Beds 

Av Beds 

per 

Nursing 

Home 

Medicare/ 

Medicaid 

Recipients 

in NFs 

Medicaid 

Expenditures 

Institutional 

LTC(1) 

Medicaid 

Medical Vendor 

Expenditures in 

NFs(1) 

CA 1,390 

(8.1) 

132,962 

(59.5) 

7.4 96 79,099 $2,530,105,425 $2,097,872,885 

ME 125 

(0.7) 

8,393 

(73.7) 

0.5 67 6,182 $263,089,445 $181,220,851 

NY 659 

(3.9) 

118,656(5) 

(81.0) 

6.6 180 96,114 $7,377,851,374 $4,906,873,789 

OH 1,007 

(5.9) 

104,817 

(59.2) 

5.8 104 62,048 $2,065,785,756 $1,569,723,823 

SD 114 

(0.7) 

7,938 

(60.1) 

0.4 70 4,767 $126,339,319 $97,951,839 

TN 352 

(2.1) 

39,275 

(74.9) 

2.2 112 29,418 $829,152,516 $619,886,256 

Nursing 

TX 1,254 

(7.3) 

125,904 

(56.4) 

7.0 100 71,064 $1,852,938,381 $1,270,530,921 

State 

Total 4,901 537,945 29.9 104 348,692 $15,045,262,21 

6 

$10,744,060,364 

U.S. 

Total 17,083 1,807,285 106 1,140,996 $40,799,455,37 

4 

$29,629,741,643 

% 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. 

__________ 

Nursing Home Medical Directors 25 OEI-06-99-00300 
APPENDIX C 

Medical Directors’ Self-reported Functions 

FUNCTIONS 

Nursing Home 

EXPECTS OR 

REQUIRES 

of Medical Director 

Medical 

Director 

SHOULD 

PERFORM 

Medical Director 

has 

AUTHORITY TO 

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 patient’s needs with financial and administrative 33 41 42 

constraints of the facility 

Develop performance indicators for attending physicians 31 60 57 

INDIVIDUAL RESIDENT’S 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 

__________ 

Nursing Home Medical Directors 26 OEI-06-99-00300 
FUNCTIONS 

Nursing Home 

EXPECTS OR 

REQUIRES 

of Medical Director 

Medical 

Director 

SHOULD 

PERFORM 

Medical Director 

has 

AUTHORITY TO 

PERFORM 

Percent of medical directors indicating “Yes” 

Secure opportunity for patients’ self-selection of attending 

physicians 

60 64 65 

Provide opportunity for patients to utilize the kitchen during 

evening hours, if able 

10 9 12 

PATIENT SERVICES 

Intervene with an attending physician when concerns are 

raised about that physician’s patient care 

92 97 93 

Review reports of consultant pharmacist’s drug regimen 

reviews 

90 93 94 

Provide ongoing medical advice and guidance to nurses 

(RNs, LVNs, LPNs, PNs) 

86 94 89 

Meet routinely with nurses to discuss patient care issues 

Perform attending physician duties 

Mediate differences or inappropriate conduct between 

providers 

Monitor the availability of attending physician services 

Participate in the planning of patient care by ensuring the 

appropriateness of services and treatments 

Monitor for appropriate patient care by attending physicians 

Monitor for appropriate consultant pharmacist performance 

Monitor the availability of any consultant services 

Serve as member of interdisciplinary team and participate in 

most or all meetings 

Interact directly with attending physicians concerning patient

care provided by nurse practitioners and physician

assistants

Verify qualifications of attending physicians 

Ensure appropriate care of patients by nurse practitioners 

and physician assistants 

Perform patient rounds, which include direct contact with 

patients 

Actively treat or supervise treatment of patients’ acute 

illnesses 

Monitor patient charts for appropriate attending physician 

documentation 

Interact directly with patients’ families concerning patients’ 

care needs 

Monitor patient care provided by nurse practitioners and 

physician assistants 

Verify qualifications of any consultants 

78 88 84 

72 83 91 

72 86 80 

72 85 84 

69 83 78 

68 85 79 

66 84 74 

64 74 72 

61 66 78 

61 78 76 

54 74 62 

54 73 65 

51 62 73 

50 54 74 

49 70 63 

48 55 69 

50 67 65 

43 68 54 

Perform comprehensive patient assessments 40 48 63 

Refer patients for nursing home admission 31 42 57 

Ensure that, upon admission, patient’s prior medical records 

and advance directives are available 

28 39 46 

__________ 

Nursing Home Medical Directors 27 OEI-06-99-00300 
FUNCTIONS 

Nursing Home 

EXPECTS OR 

REQUIRES 

of Medical Director 

Medical 

Director 

SHOULD 

PERFORM 

Medical Director 

has 

AUTHORITY TO 

PERFORM 

Percent of medical directors indicating “Yes” 

Lead or chair the development of medical interdisciplinary 

health-care plans for all patients 

27 47 47 

Meet routinely with nurse aides to discuss patient care 

issues 

24 40 48 

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 

PNs) per shift 

3 13 3 

Ensure sufficient nurse aide coverage per shift 3 11 4 

ADMINISTRATION AND MANAGEMENT 

Provide medical expertise for facility when necessary to 

respond to regulatory agency survey concerns 

94 96 96 

Liaison between medical staff, nursing staff, and 

administration 

84 88 89 

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, 

nursing staff, and administration 

49 62 68 

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 

physicians appropriate and necessary patient medical 

information 

Teach nursing staff, including aides, that certain drugs are 

inappropriate for elderly patients 

Teach attending physicians about state and federal 

regulations 

Educate health-care staff on new policies and procedures 

Promote on-going training of medical and non-medical staff 

related to their functional requirements 

Provide training on health-care ethics 

Teach nursing staff, including aides, about state and federal 

regulations 

54 68 70 

53 71 70 

38 57 56 

37 51 55 

36 45 46 

34 50 59 

28 38 42 

Teach the aging process to direct care staff, other than 

nursing staff (e.g., social worker, dietitian, etc.) 

25 42 51 

Provide training to community regarding nursing home 

services, possible care choices, and patient’s rights 

22 35 44 

ENSURING A SAFE PHYSICAL ENVIRONMENT 

Promote a hazard-free resident environment 32 46 40 

Ensure occurrence of emergency evacuation and safety 

drills 

21 26 29 

Promote noise control 18 33 28 

__________ 

Nursing Home Medical Directors 28 OEI-06-99-00300 
FUNCTIONS 

Nursing Home 

EXPECTS OR 

REQUIRES 

of Medical Director 

Medical 

Director 

SHOULD 

PERFORM 

Medical Director 

has 

AUTHORITY TO 

PERFORM 

Percent of medical directors indicating “Yes” 

Verify facility’s sanitary storage, preparation, and service of 

food 

Confirm facility’s adequate and comfortable lighting levels for 

patients 

12 22 26 

11 22 25 

__________ 

Nursing Home Medical Directors 29 OEI-06-99-00300 
__________

Nursing Home Medical Directors 30 OEI-06-99-00300

ACKNOWLEDGMENTS

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 General’s

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/