CMS SOM App. H, Tag V561

The interdisciplinary team

must—

(1) Track the results of each kidney transplant center referral;

(2) Monitor the status of any facility patients who are on the transplant wait list; and

(3) Communicate with the transplant center regarding patient transplant status at least

annually, and when there is a change in transplant candidate status.

Interpretive Guidance § 494.90(c)(1), (2) and (3)

Average waiting times for receiving a kidney transplant may be 3-5 years for most transplant

programs, and even longer in some geographical regions of the country. The ability to receive a

transplant will vary based on health, compatibility, and availability of organs. Requiring the

facility to track patients’ transplant referrals and their status on the transplant wait list is

intended to enhance the communication and coordination between the transplant center and the

dialysis facility so that patients do not get “lost” along the way in the transplant referral,

evaluation, and waiting period.

Tracking completion of the tests and evaluations required for a transplant work up and waiting

list active status is primarily the responsibility of the patient in partnership with the transplant

center. However, by communicating and coordinating activities with the transplant center, the

dialysis facility IDT may be able to adjust their plan of care to facilitate the patient’s

transplantation goal. This communication should be systematic and documented.

A “change in status” refers to a medical or psychosocial event that could either temporarily or

permanently change a transplant patient’s ability to receive a transplant. The “change” could

either enhance or limit a dialysis patient’s opportunities to receive a transplant. Examples of

status change events include cardiac events, weight loss, cessation of smoking, patient death or

identification of a new potential living organ donor. The transplant center should be notified at

the time of any change in status.

The facility’s patient transplant referral/waiting list status tracking may be centralized, but must

also be documented in each referred patient's medical record.