Policies Posted for Comment
Draft and recently signed policies are posted here for review and comment by The
University of Toledo community for thirty days. Draft policies do not have official
status as approved policies until the Approving Officer has signed the policies. Some
policies may be signed in advance of the vetting period to comply with the requirement
of federal or state laws or regulations or accrediting agencies.
Please direct any comments or questions regarding the policies posted for comment to policies@utoledo.edu or click on the icon under "comment on this policy." Please state the name of the policy in the subject line. Comments received on the policy will be forwarded to the policy's responsible agent or agent's designee.
To join our mailing list for email notification of updates and additions to the Policies Posted for Comment, please send an email to policies@utoledo.edu with "policies posted for comment" in the subject line.
NOTE: The University’s policies ultimately become a part of the Ohio Administrative Code. The Administrative Code is written in lower case. As each UT policy comes due for review, it will be formatted according to the Ohio Legislative Service Commission Drafting Manual. Many words that normally would be capitalized will not be capitalized in the text of the policy. For example – university of Toledo, president of the United States, supreme court, holidays such as Christmas day (Christmas is capitalized but day is not). The Drafting Manual includes many other grammatical guidelines. The header box and the signature box do not need to comply with these rules. Please do not send comments asking to revise capitalization, outline format, grammar, etc.
The following policies have been posted for the 30-day comment period:
University Faculty – 1 policy
Policy Name: 3364-72-08 Emeritus faculty
Description: (Minor Revisions) Minor revisions defining scope and privileges of emeritus faculty.
Scope: All Faculty
Comment Period: May 22, 2025 through June 23, 2025
Comment on this policy: 3364-72-08
GME – 1 policy
Policy Name: 3364-86-046-00 Accommodations for residents with disabilities
Description: (Minor/technical revision of existing policy) Change from Program Director initiating resident’s request for ADA accommodations.
The resident must submit an ADA accommodation request form via the Workplace Accommodations
website.
Scope: UT College of Medicine Residents
Comment Period: May 2, 2025 through June 3, 2025
Comment on this policy: 3364-86-046-00
College of Medicine & Life Sciences - 1 policy
Policy Name: 3364-81-04-006-01 Supervision and Teaching of Medical Students
Description: (Minor Revisions) Minor revisions with the addition of a statement about Conflict of Interest and Nepotism
under the Procedure section.
Scope: College of Medicine MD Program
Comment Period: May 22, 2025 through June 23, 2025
Comment on this policy: 3364-81-04-006-01
UTMC - 36 policies
Policy Name: 3364-100-50-43 Patient Status Assignment
Description: (Major Revisions) Updated criteria for determining patient status in the policy statement and procedure.
Updated policy purpose to include the appropriateness of patient status based on medical
necessity. Removed reference to former record of care and added Electronic Medical
Record/EMR. Clarified responsibility of the Resource Utilization Committee, Coordinator
and physicians related to medical necessity. Other minor grammatical and format changes.
Scope: University of Toledo Medical Center
Comment Period: May 22, 2025 through June 23, 2025
Comment on this policy: 3364-100-50-43
Policy Name: 3364-131-02 Post Acute Placement
Description: (Major Revisions) Removed reference to Extended Care Facility to Post-Acute throughout policy. Updated
Procedure criteria, medical review and documentation for the placement of patient
into a post-acute facility. Other minor grammatical and format changes.
Scope: University of Toledo Medical Center
Comment Period: May 22, 2025 through June 23, 2025
Comment on this policy: 3364-131-02
Policy Name: 3364-131-03 Home Health Care Referrals
Description: (Major Revisions) Updated policy purpose to include a standardized process and goal to ensure patients
who are eligible for home health services receive appropriate, timely, and coordinated
care in their home environment, promoting continuity of care and improving health
outcomes. Updated procedure criteria for home health care companies, referrals, and
documentation. Other minor grammatical and format changes.
Scope: University of Toledo Medical Center
Comment Period: May 22, 2025 through June 23, 2025
Comment on this policy: 3364-131-03
Policy Name: 3364-131-28 Discharge Assessment of Acute Care Inpatients
Description: (Minor Revisions) Updated policy purpose removing early discharge language. Updated procedure high
risk guidelines to add change in level of care and added assessment criteria. Other
minor grammatical and format changes.
Scope: University of Toledo Medical Center
Comment Period: May 22, 2025 through June 23, 2025
Comment on this policy: 3364-131-28
Policy Name: 3364-138-21 STAT (Emergent) Electroencephalogram
Description: (New Policy) New policy created to establish guidelines for ordering STAT EEG studies including
Long Term Monitoring Epilepsy (LTME). Policy provides clarification to the process
of identifying the priority of EEG/LTME, indications for STAT studies, and ordering
requirements.
Scope: University of Toledo Medical Center, Neurodiagnostic Services
Comment Period: May 22, 2025 through June 23, 2025
Comment on this policy: 3364-138-21
Policy Name: 3364-133-118 Inadequate Resident Performance and Corrective Action
Description: (Major Revisions) Clarified residency expectations. Removed offenses and added examples of performance
issues with course of action. Updated procedure to include written documentation
of corrective action as appropriate.
Scope: University of Toledo Medical Center
Comment Period: May 22, 2025 through June 23, 2025
Comment on this policy: 3364-133-118
Policy Name: 3364-107-412 Delegation of Medical Directorship Tasks
Description: (New policy) New policy created to establish laboratory director delegation of tasks and functions
as defined by CLIA an CAP. The purpose of the policy is to outline what laboratory
tasks can be delegated and to what title/role.
Scope: University of Toledo Medical Center
Comment Period: May 22, 2025 through June 23, 2025
Comment on this policy: 3364-107-412
Policy Name: 3364-110-05-08 Qualifications for Oncology Nurses Providing Direct Patient Care and
to Administer Antineoplastic Chemotherapy
Description: (Major Revisions) Added policy reference to all nurses providing direct patient care in the policy title.
Updated policy statement and procedure to include Commission on Cancer language for
required competency, and hours of education required per accreditation cycle.
Scope: University of Toledo Medical Center
Comment Period: May 22, 2025 through June 23, 2025
Comment on this policy: 3364-110-05-08
Policy Name: 3364-100-50-23 Adjustment of University of Toledo Medical Center Charges
Description: (Minor Revisions) Updated reference to the Claims Management Committee for review and approvals. Removed
reference to specific departments or individuals.
Scope: University of Toledo Medical Center
Comment Period: May 22, 2025 through June 23, 2025
Comment on this policy: 3364-100-50-23
Policy Name: 3364-100-50-02 Disaster responsibilities for volunteer health care professionals
Description: (Minor/technical revision of existing policy) Added chief nursing officer or assigned designee to the list of individuals responsible
for assigning disaster responsibilities to volunteer health care professionals.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: May 2, 2025 through June 3, 2025
Comment on this policy: 3364-100-50-02
Policy Name: 3364-100-50-31 Approval of standard care arrangements for hospital-employed advanced
practice nurses
Description: (Minor/technical revision of existing policy) Removed APN and added APRN in reference to Advanced Practice Nurses. Added reference
to Clinical Nurse Specialist titles, including those in mental health, are required
to enter into a standard care agreement with one or more collaborating physicians;
whose practice is similar to the nurse’s specialty. The Clinical Nurse Specialist
will meet requirements as outlined in the Ohio State Board of Nursing.
Scope: University of Toledo Medical Center and Medical Staff
Comment Period: May 2, 2025 through June 3, 2025
Comment on this policy: 3364-100-50-31
Policy Name: 3364-100-01-16 Patient identification
Description: (Minor/technical revision of existing policy) Removed reference to Kobacker policy 3364-122-39 and added reference to Kobacker
Identification Guidelines.
Scope: University of Toledo Medical Center
Comment Period: May 2, 2025 through June 3, 2025
Comment on this policy: 3364-100-01-16
Policy Name: 3364-103-VS-20 Volunteer requirements at the University of Toledo Medical Center and
Patient Clinics
Description: (Minor/technical revision of existing policy) Change in location of the Volunteer Services Office from Dowling Hall to Mulford
Library Annex.
Scope: University of Toledo Medical Center
Comment Period: May 2, 2025 through June 3, 2025
Comment on this policy: 3364-103-VS-20
Policy Name: 3364-103-VS-14 Benefits
Description: (Minor/technical revision of existing policy) Changes to benefits section – removing prescription benefit and access to Morse
Physical Fitness and Student Recreation Center.
Scope: University of Toledo Medical CenterComment Period: May 2, 2025 through
June 3, 2025
Comment on this policy: 3364-103-VS-14
Policy Name: 3364-100-01-12 EMS Bypass
Description: (Minor/technical revision of existing policy) Spelled out “EMS” – Emergency Medical System and “ED” – Emergency Department for
accessibility purposes. Under procedure added “or designee” after reference to the
Medical Director of the Emergency Department for initiation of EMS Bypass.
Scope: University of Toledo Medical Center and its Medical Staff
Comment Period: May 2, 2025 through June 3, 2025
Comment on this policy: 3364-100-01-12