CMS SOM App. H, Tag V714

The medical director must— (1) Participate in the

development, periodic review and approval of a “patient care policies and procedures

manual” for the facility; and

Interpretive Guidance § 494.150(c)(1):

Written patient care policies and procedures are essential references for clinical staff and should

reflect current practices at the facility. The patient care policies and procedures should address

all areas of patient assessment and care delivery for the dialysis modalities provided, and these

policies and procedures should reflect both these regulations and current practice standards, as

well as adherence to equipment manufacturers’ instructions for use.

There must be evidence that the medical director reviewed and approved the patient care

policies and procedures and any revisions as they are made. Corporate-owned or corporate-

managed facilities may use standard policies and procedures developed by the corporation.

There should be a mechanism for the facility medical director to have input into the policies and

procedures, and to have some authority to individualize corporate policies to address unique

facility situations.

Policies are expected to be adequate, accurate, and up-to-date.