US · guidance
CMS SOM App. Y, Tag Z166
(Standard) §486.342(b) If an OPO does not request consent to donation because a
potential donor consented to donation before his or her death in a manner that
satisfied applicable State law requirements in the potential donor’s State of
residence, the OPO must provide information about the donation to the family of
the potential donor, as requested.
Interpretive Guidelines §486.342(b)
Request the OPO’s written protocol for contacting family or legally authorized
representatives in the case of first person donation. Ensure that the OPO is following its
written protocol.
Review a sample of donor records where no family or legally authorized representative’s
consent was required (e.g., living will, advance directive, driver’s license declaration with
informed consent and State donor registries).
Verify that the OPO followed applicable State laws regarding first person consent.
Documentation in the donor record should confirm that the OPO made every attempt to
make contact with family or legally authorized representatives to provide additional
information to them regarding the expected process of donation. Instances where the
OPO attempted but was unable to make contact should be documented. Look for any
instances where a donor family or legally authorized representatives requested additional
information about the donation and verify that the OPO provided the information.
History
Rev. 115, Issued: 05-23-14, Effective: 05-23-14, Implementation: 05-23-14
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
8d82652331f5a906fd139da25fd5be8be3b256409446d2b31a6482a27feb4f2c
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