CMS SOM App. H, Tag V501

§ 494.80 - The facility’s interdisciplinary team, consists of, at a minimum, the patient or

the patient’s designee (if the patient chooses), a registered nurse, a physician treating the

patient for ESRD, a social worker, and a dietitian. The interdisciplinary team is responsible

for providing each patient with an individualized and comprehensive assessment of his or

her needs. The comprehensive assessment must be used to develop the patient’s treatment

plan and expectations for care.

Interpretive Guidance §494.80

While multidisciplinary team members work sequentially and use the medical record as the chief

means of communication, IDTs work collaboratively with regular meetings to discuss patient

status and the evolving plan of care. Working as a team allows for working toward common

goals, pooling of expertise, and a forum for problem solving.

The IDT is composed of the members designated in the regulations, including the patient or a

patient designee if the patient so chooses. Patients must be given the option and encouraged to

participate in their assessment and care planning process. The professional members of the IDT

participating in the patient's comprehensive assessment must meet the qualifications outlined in

the Conditions for Personnel Qualifications at § 494.140.

“Individualized” means each assessment is unique to a particular patient and addresses that

patient’s needs. “Comprehensive” means the assessment covers and addresses all issues that are

actionable by the dialysis facility; this could include referrals to specialists for assessments that

are beyond the capacity of a dialysis facility.

The comprehensive patient assessment must demonstrate a congruent integration of the

evaluations completed by each team member, identifying the patient’s individual needs and

allowing for planning for necessary care and services. Team members may choose to conduct

one-on-one interviews with the patient or may opt to set up team meetings which would include

the patient in order to collect the appropriate assessment information.

This assessment may be incorporated into one document or composed of sections developed by

each team member, but it must address the specific criteria as outlined in V502-V515. Electronic

or paper formats are acceptable.

Required frequencies of patient assessments are addressed at V516- V520.