CMS SOM App. A, Tag A-0891

tissue bank and eye bank in educating staff on donation issues;

Interpretive Guidelines §482.45(a)(5)

Appropriate hospital staff, including all patient care staff, must be trained on donation issues.

The training program must be developed in cooperation with the OPO, tissue bank and eye bank,

and should include, at a minimum:

• Consent process;

• Importance of using discretion and sensitivity when approaching families;

• Role of the designated requestor;

• Transplantation and donation, including pediatrics, if appropriate;

• Quality improvement activities; and

• Role of the organ procurement organization.

Training should be conducted with new employees annually, whenever there are

policy/procedure changes, or when problems are determined through the hospital’s QAPI

program.

Those hospital staff who may have to contact or work with the OPO, tissue bank and eye bank

staff must have appropriate training on donation issues including their duties and roles.

Survey Procedures §482.45(a)(5)

• Review in-service training schedules and attendance sheets.

• How does the hospital ensure that all appropriate staff has attended an educational

program regarding donation issues and how to work with the OPO, tissue bank, and eye

bank?