CMS SOM App. Y, Tag Z121

(1) The OPO must provide sufficient coverage, either by its own staff or under contract or

arrangement, to assure both that hospital referral calls are screened for donor potential

and that potential donors are evaluated for medical suitability for organ and/or tissue

donation in a timely manner.

Interpretive Guidelines §486.326(b)(1)

Review the OPO written policy on the screening of incoming hospital referral calls.

Policies should include who may conduct the screening, the screening process to be

followed, the time frame for completing the screening and the documentation that must

be entered into the intake record. Also, review the OPO written policy on the timeframes

for subsequent OPO staff arrival at the hospital and evaluation.

As a part of the donor record review, verify that the OPO policies for screening are being

followed.