CMS SOM App. Z, Tag E-0012

programs. A transplant program must be included in the emergency preparedness

planning and the emergency preparedness program as set forth in § 482.15 for the

hospital in which it is located. However, a transplant program is not individually

responsible for the emergency preparedness requirements set forth in § 482.15.

(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.

(b) Standard: Protocols with hospital and OPO. A transplant program must

develop and maintain mutually agreed upon protocols that address the duties and

responsibilities of the transplant program, the hospital in which the transplant

program is operated, and the OPO designated by the Secretary, unless the hospital

has an approved waiver to work with another OPO, during an emergency.

Interpretive Guidelines applies to: §482.78(a), and §482.78(b).

Hospitals which have transplant programs must include within their emergency planning

and preparedness process one representative, at minimum, from the transplant program.

If a hospital has multiple transplant programs, each program must have at least one

representative who is involved in the development and maintenance of the hospital’s

emergency preparedness process. The hospital must include the transplant programs in

its emergency preparedness plan policies and procedures, communication plans, as well

is the training and testing programs.

Both the hospital and the transplant programs are required to demonstrate during a survey

that they have coordinated in planning and the development of the emergency program.

Both are required to have written documentation of the emergency preparedness plans.

However, the transplant programs is not individually responsible for the emergency

preparedness requirements under §482.15.

Survey Procedures

• Verify the hospital has written documentation to demonstrate that a representative of

each transplant programs participated in the development of the emergency program.

• Ask to see documentation of emergency protocols that address transplant protocols

that include the hospital, the transplant programs and the associated OPOs.