US · guidance
CMS SOM App. Z, Tag E-0005
§482.78(a) Standard: Policies and procedures
A transplant program must have
policies and procedures that address emergency preparedness. These policies and
procedures must be included in the hospital’s emergency preparedness program.
Interpretive Guidelines for §482.78(a).
Transplant programs must be actively involved in their hospital’s emergency planning
and programming under §482.15(g). The transplant program’s emergency preparedness
plans must be included in the hospital’s emergency plans. All of the Medicare-approved
transplant programs are located within certified hospitals and, as part of the hospital,
must be included in the hospital’s emergency preparedness plans. The transplant
program needs to be involved in the hospital’s risk assessment because there may be risks
to the transplant program that others in the hospital may not be aware of or appreciate.
However, most of the risk assessment of the hospital and transplant program would be
the same since the transplant program is located within the hospital. Therefore a separate
risk assessment would be unnecessary and overly burdensome.
Survey Procedures
• Verify the transplant program has emergency preparedness policies and procedures.
• Verify that the transplant program’s emergency preparedness policies and procedures
are included in the hospital’s emergency preparedness program.
History
Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20
Provenance
- Source
- cms.gov
- Retrieved
- 2026-07-22
- Edition
- som-2026-07-22
- Content hash
d65721e566950ebf57d1898c24df1cca004326c6e94aaa4823a798182f818548
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