CMS SOM App. A, Tag A-0892

[Ensure that the hospital works cooperatively with the designated OPO, tissue bank and

eye bank in educating staff on…] reviewing death records to improve identification of

potential donors, and

Interpretive Guidelines §482.45(a)(5)

Hospitals must cooperate with the OPOs, tissue banks and eye banks in regularly or periodically

reviewing death records. This means that the hospital must develop policies and procedures

which permit the OPO, tissue bank, and eye bank access to death record information that will

allow the OPO, tissue bank and eye bank to assess the hospital’s donor potential, assure that all

deaths or imminent deaths are being referred to the OPO in a timely manner, and identify areas

where the hospital, OPO, tissue bank and eye bank staff performance might be improved. The

policies must address how patient confidentiality will be maintained during the review process.

Survey Procedures §482.45(a)(5)

• Verify by review of policies and records that the hospital works with the OPO, tissue

bank, and eye bank in reviewing death records.

• Verify that the effectiveness of any protocols and policies is monitored as part of the

hospital’s quality improvement program.

• Validate how often the reviews are to occur. Review the protocols that are in place to

guide record reviews and analysis.

• Determine how confidentiality is ensured.