Medical Director

Medical Director 

Effective Date: [Original NPP Date] 
Revised Date: [Current Date] 

Standard: 

The facility has a designated licensed physician to serve as Medical Director. 

Policy: 

The Medical Director, in collaboration with the facility’s Administrator and Director of Nurses, coordinates the medical care and oversees the implementation of resident care policies. 

Practice Guidelines: 

• Licensure: 

• The Medical Director is a licensed physician. 

• Coordination of Medical Care: 

• The Medical Director is involved in the coordination of medical care within the facility. 

• Availability: 

• The Medical Director provides services to the facility 24 hours per day. 

• Medical Orders and Reviews: 

• The Medical Director provides medical orders and reviews a resident’s medical condition as required. 

• Oversight of Practitioners: 

• The Medical Director assures that other practitioners who may perform physician-delegated tasks act within the regulatory requirements and within their scope of practice as defined by State law. 

• Response to Acute Changes: 

• The Medical Director responds to staff when another MD fails to respond to a request to evaluate or discuss a resident with an acute change of condition. 

• Timely Response and Assistance: 

• The Medical Director is expected to respond timely and assist the staff in obtaining needed consultations or other medical services. 

• Assistance with Resident Care Policies: 

• The Medical Director assists the administrative staff with any issues regarding resident care policies. 

• QA Committee Involvement: 

• The Medical Director is an active member of the Quality Assurance (QA) Committee. 

• Policy and Procedure Input: 

• The Medical Director must have input for reviewing and approving policies and procedures for resident care. 

References: 

• Centers for Medicare & Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities. [Link to current CMS SOM] 

• CMS Requirements of Participation for Long-Term Care Facilities. [Link to current guidelines]