CMS SOM App. H, Tag V715

§ 494.150(c) Policies and procedures. The medical director must— (2) Ensure that— (i) All

policies and procedures relative to patient admissions, patient care, infection control, and

safety are adhered to by all individuals who treat patients in the facility, including

attending physicians and nonphysician providers; and

Interpretive Guidance § 494.150(c)(2)(i):

The medical director is responsible for implementing policies and procedures for all staff. This

includes holding medical staff accountable for complying with facility policies and procedures,

such as updating plans of care, signing verbal orders, and being knowledgeable about the QAPI

targets, as well as working to achieve those targets with their patients. In reviewing the

performance of the medical staff, the medical director should consider using currently-available

methods, such as practitioner profiles, to review and evaluate performance.

The medical director is responsible for ensuring that the facility has an established policy

regarding patient admissions to the facility. Policies for patient admission should address the

expectation for an initial assessment by a member of the medical staff (i.e., physician, APRN or

PA) before the initiation of the patient’s first dialysis treatment in the facility. The initial

assessment, which may be a review of the patient’s medical record or may be conducted in

person, allows the medical team to develop the admission treatment orders and recognize any

urgent patient medical needs (e.g., anemia with Hgb < 10g/dl, fluid overload, hyperkalemia) that

require immediate action.

Note: The initial evaluation, which occurs prior to the patient’s initial dialysis treatment upon

admission, is separate and distinct from the routine pre-treatment assessment which occurs prior

to each dialysis session.

Orders for treatment must be in place prior to the initial treatment, as well as a patient

evaluation by a registered nurse for any immediate needs. At the time of publishing these

regulations (April 15, 2008, 73FR20369), according to the American Nephrology Nurses’

Association, the minimal nursing evaluation prior to initiating treatment for a patient new to the

facility should include:

1. Neurologic: level of alertness/mental status, orientation, identification of sensory deficits

2. Subjective Complaints

3. Rest and comfort: pain status

4. Activity: ambulation status, support needs, fall risk

5. Access: assessment

6. Respiratory: respirations description, lung sounds

7. Cardiovascular: heart rate and rhythm; presence and location of edema

8. Fluid gains, blood pressure and temperature pre-treatment

9. Integumentary: skin color, temperature and as needed, type/location of wounds

Note that other parts of these regulations address adherence to policies and procedures as

applicable to specific Conditions, e.g., infection control at V142, water and dialysate quality at

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V259, reuse at V306, and physical environment at E-0013. Generally, these more specific tags

should be used for deficient practices identified in those areas.