CMS SOM App. H, Tag V710

Interpretive Guidance § 494.150:

Page 271 of 420

This Condition defines the role the facility medical director is expected to assume to ensure the

delivery of quality patient care and clinical outcomes. Most deficient practices identified in the

delivery of quality patient care and patient clinical outcomes are most appropriately cited under

the Conditions pertinent to the practice (e.g., infection control practices, lack of patient

assessment or plan of care implementation). Citation of these standards or this Condition should

be considered when deficient practices are pervasive, the results of the deficient practices are

egregious, or the deficient practice identified is not covered under other Conditions.

Determine compliance with this Condition by patient and staff interviews, review of clinical and

QAPI records and review of survey findings related to care delivery, patient assessments and

plans of care, water and dialysate quality, reuse, and QAPI.

Examples of Condition level noncompliance include, but are not limited to:

• Serious and/or pervasive problems/trends identified in the quality of care delivery, QAPI

activities; and,

• Significant deficient practices in patient care policy and procedure development or

implementation in which a lack of involvement and oversight by the medical director was

a contributing factor.