CMS SOM App. Y, Tag Z164

An OPO must encourage discretion and sensitivity with respect to the circumstances,

views, and beliefs of potential donor families.

Interpretive Guidelines §486.342

Before going on-site, review the Aspen Complaint/Incident Tracking System (ACTS) to

determine if any complaints have been filed against the OPO for inappropriate or

insensitive behavior during the process of obtaining consent. If so, determine if there is

any additional follow-up required or were the complaints resolved sufficiently?

In the absence of first person consent, while it may be assumed by the OPO that, in

general, all persons, regardless of religious or personal beliefs, may be approached for

organ donation, the OPO must be sensitive to any factors (from record review, hospital

staff information, their own knowledge regarding religious beliefs or information

received) which indicate that the OPO should not pursue consent. The OPO must respect

the decisions by the family or the legally authorized representative as determined by State

law. Declination must be respected if the family or legally authorized representative was

approached by a trained requestor and declined donation. Review the staff orientation

program for discussions on sensitivity with donor families and legally authorized

representatives.

Review the QAPI documentation to determine if the OPO program conducted analysis on

any complaints received from family members or legally authorized representatives

reporting insensitive behavior or lack of discretion on the part of the OPO staff. Review

OPO documentation of subsequent counseling and increased training that was provided

to any staff member involved in such a complaint.