As a new DON, what duties should I expect from the Medical Director?




The duties of the Medical Director are addressed in the CMS regulations as follows:

      • F841
      • 483.70(h) Medical director.
      • 483.70(h)(1) The facility must designate a physician to serve as medical director.
      • 483.70(h)(2) The medical director is responsible for—
        • Implementation of resident care policies; and
        • The coordination of medical care in the facility.

The regulation specifies the following responsibilities of the Medical Director which include their participation in:

        • Administrative decisions including recommending, developing and approving facility policies related to residents care. Resident care includes the resident’s physical, mental and psychosocial well-being;
        • Issues related to the coordination of medical care identified through the facility’s quality assessment and assurance committee and other activities related to the coordination of care;
        • Organizing and coordinating physician services and services provided by other professionals as they relate to resident care;
        • Participate in the Quality Assessment and Assurance (QAA) committee or assign a designee to represent him/her. (Refer to F865).

In addition, the regulation goes on to specify the following responsibilities:

        • Ensuring the appropriateness and quality of medical care and medically related care;
        • Assisting in the development of educational programs for facility staff and other professionals;
        • Working with the facility’s clinical team to provide surveillance and develop policies to prevent the potential infection of residents. Refer to Infection Control requirement at §483.80;
        • Cooperating with facility staff to establish policies for assuring that the rights of individuals (residents, staff members, and community members) are respected;
        • Supporting and promoting person-directed care such as the formation of advance directives, end-of-life care, and provisions that enhance resident decision making, including choice regarding medical care options;
        • Identifying performance expectations and facilitating feedback to physicians and other health care practitioners regarding their performance and practices;
        • Discussing and intervening (as appropriate) with a health care practitioner regarding medical care that is inconsistent with current standards of care; and
        • Assisting in developing systems to monitor the performance of the health care practitioners including mechanisms for communicating and resolving issues related to medical care and ensuring that other licensed practitioners (e.g., nurse practitioners) who may perform physician-delegated tasks act within the regulatory requirements and within the scope of practice as defined by State law.

As you can see, it would be both essential and beneficial to have regular meetings with the Medical Director to review these responsibilities and document their involvement. Consider using this document to assist with this process.


Janine Lehman, RN, RAC-CT, CLNC
Director of Legal Nurse Consulting

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