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Federal regulations require that all nursing facilities seeking Medicare or Medicaid reimbursement have a governing body and employ certain defined personnel.9 The governing body or those empowered to act as the governing body are legally responsible for setting and enacting the policies and procedures of the facility. These same regulations require facilities to employ an administrator, designated nursing staff, social services personnel, dietary staff, an activities director, medical director and staff, pharmacist, dentist, rehabilitation personnel, and housekeeping/maintenance personnel. The roles of key staff as described by federal regulations are outlined below. State and local agencies may place more stringent requirements on facilities. Some latitude is also granted to small and rural facilities in terms of staffing requirements in recognition of the difficulty in recruiting licensed personnel.

1. Nursing Home Administrator. The nursing home administrator is appointed by the governing body. Federal regulations require that a nursing home be supervised by an administrator licensed by the state. The administrator is charged with management of the facility. He/she is expected to administer the facility in a manner that allows each resident to maximize physical, mental and psychosocial well-being.

2. Director of Admissions. There is no separate federal designation for the position of director of admissions. This position frequently exists in nursing facilities to coordinate the large numbers of admissions, discharges, and beds being held for persons in the hospital. The director of nursing, a social worker, an assistant administrator, or other personnel associated with the nursing home may fill this position.

3. Director of Social Services. Each facility is required to provide medically-related social services to attain or maintain the highest practical physical, mental, and psychological well-being of the resident. Facilities with more than 120 beds are required to employ a full-time social worker. The broad mandate of the social worker may include activities such as coordinating eye care, maintaining contact with the resident’s family, coordinating health and medical decisions between staff and residents, and assisting the resident in obtaining legal or other services.

4. Director of Nursing. Each facility must have a registered nurse that serves as the director of nursing. The director of nursing acts largely in a supervisory capacity to ensure that the goals for each resident assessment and care plan are met. The director of nursing may serve as a charge nurse only in small facilities. Unlicensed nursing assistants provide much of the direct care to residents. Federal guidelines describe the type of care that may be provided and educational requirements for these positions.

5. Director of Activities. Each facility must employ a qualified professional to serve as director of the activities program. This may be a therapeutic recreation specialist, or, in some circumstances, an occupational therapist or occupational therapy assistant. The role of the activities director is to provide activities for the residents that help them achieve their highest possible level of function. These are based on the individual resident’s preference and might include music, reading, and social gatherings.

6. Medical Director. Each facility must appoint a physician to serve as medical director. The medical director provides, directs, and coordinates medical care in the facility. Duties of the medical director include development of written rules and regulations and delineation of the responsibilities of attending physicians. Coordination of medical care includes liaison with attending physicians to ensure that physicians' orders are written promptly upon admission of a resident, that periodic evaluations of the adequacy and appropriateness of health professional and supportive staff and services are conducted, and that the medical needs of the residents are met.

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