Some Nursing Home Medical Directors Are Going Missing When CMS Enforcement Hits — and Two State Officials Just Said It Out Loud

Washington, D.C. — When a nursing home enters a federal enforcement cycle, the medical director can be the difference between a corrective plan and a closure order. Two state regulators say too many of them are missing in action when it counts.

Lisa Davies, chief operating officer for the Medical Assistance Plans Division at the Georgia Department of Community Health, and Heather Chamizo, staff services manager for California’s Department of Public Health Center for Health Care Quality, told industry sources the role has changed sharply since 2016, when CMS revised its requirements of participation in Medicare and Medicaid.

The job now reaches well beyond clinical sign-offs. Medical directors are expected to drive Quality Assurance and Performance Improvement programs, review high-risk policies, and serve as a stabilizing force when surveys go sideways.

The cycle that decides everything

Once a facility receives deficiencies, it lands in what regulators call an enforcement cycle — a sequence of plans of correction, fines, and revisit surveys. Davies said operators don’t get unlimited chances to clean up.

“Revisit surveys end the enforcement cycle, but they are not unlimited,” she said. “If you get past a fourth revisit, only the central office of CMS can approve a fifth or sixth revisit, and they can choose at any point in time to stop approving the revisits.”

Facilities have six months to return to substantial compliance or face mandatory termination from federal funding. Immediate Jeopardy violations that go uncorrected trigger closure within 23 days. That’s when medical directors should be camped out in the building, Davies argued — and the data on troubled facilities suggests heightened federal scrutiny on struggling operators isn’t easing up.

Attending versus participating

The regulators kept circling back to one question every medical director should be asking: am I attending these quarterly meetings, or actually participating in them?

“It can make a key difference in the quality of the nursing home,” Davies said. Active involvement in falls prevention, wound care policy, and QAPI work catches problems before they show up on a survey.

Chamizo said the role gets even more critical when a facility shuts down. Residents have just 30 days to relocate, and medical directors have to coordinate transfers, maintain continuity of care, and stay in constant contact with state agencies, CMS, ombudsmen, and facility leadership.

One California closure she described forced ventilator-dependent residents to be transferred hundreds of miles away.

“They should be on those phone calls. They should be in that facility more than they have ever been before, to make sure that there is not a decline in the quality of care that happens as those doors are closing,” Davies said. “I will say that I’ve been part of closures where the medical director has been absent.”

Why the absence matters

The job pays. The title carries weight. But state regulators are telling operators bluntly that signing the contract isn’t the same as doing the work — and when CMS pulls funding, residents pay the price for whoever wasn’t in the room.