OPTN Evaluation Plan - Organ Procurement and Transplantation ...

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Policy 16.7.B: Vessel StorageOPTN Member Evaluation PlanUpdated January 1, 2015Effective Date: 2/1/2014At transplant hospitals, site surveyors will:Review the transplant hospital’s internal policies, procedures and/or protocols and/or interview key clinical personnelto verify that they address:⦁ Whether HCV+ or HbSAg+ vessels are stored for later use⦁ Notifying the OPTN of vessel disposition⦁ Having vessel information available to the transplant surgeon at all times⦁ Storage, monitoring, and disposing of vessels⦁ Monitoring the temperature of the refrigerator where the vessels are stored⦁ Destruction of vessels within 14 days after the recovery dateReview a sample of vessel monitoring logs to verify that:⦁ There is a vessel log⦁ Vessel disposition is documented⦁ Vessels are stored no more than 14 days after the recovery dateReview temperature monitoring logs for the review period to verify that:⦁ The temperature of the vessel storage refrigerator was maintained no lower than 2° C or higher than 8° Cduring the audit time frame⦁ There were daily security and temperature checksVisually inspect currently stored vessels to verify that:⦁ The vessels are packaged and labeled as required by Policy 16.4: Packaging and Labeling.Transplant hospitals will provide:The transplant hospital's internal policies, procedures and protocols for the care of candidates and recipientsEvidence as needed to verify complianceAccess to relevant staff who can answer interview questions40
OPTN Member Evaluation PlanUpdated January 1, 2015Policy 18.1: Data Submission RequirementsEffective Date: 7/3/2014At OPOs, site surveyors will:Review rates of compliance with submission dates for the following forms submitted to the OPTN within the reviewtimeframe:⦁ Deceased Donor Registration (DDR)⦁ Deceased Donor Feedback⦁ Potential Transplant Recipient (PTR) refusal codesOPOs will provide:At Living Donor recovery hospitals, site surveyors will:Review rates of compliance with submission dates for LDRs submitted to the OPTN within the review timeframe.Review a sample of living donor medical records, and any material incorporated into the medical record byreference, for documentation that:⦁ The date and time of the registration of the donor via UNet℠ occurred before the date and time of the startof the recoveryReview a sample of living donor medical records, and any material incorporated into the medical record byreference, to verify that data reported through UNet℠ is consistent with source documentation, including:⦁ The following donor information is reported on the LDR:⦁ Donor ID⦁ Donor date of birth⦁ SSN⦁ ABO⦁ Serologies⦁ Height⦁ Weight⦁ Conversion from laparoscopic⦁ Organ recovery date⦁ Organ recovered⦁ Recipient name⦁ Recipient SSN⦁ Recovery facility⦁ Workup facility⦁ Discharge dateRecovery hospitals will provide:The requested sample of living donor recordsEvidence as needed to verify compliance41
Page 1 and 2: OPTN Member Evaluation PlanUpdated
Page 3 and 4: Policy 8.5.A: Candidate Classificat
Page 9 and 10: Policy 2.8: Required Deceased Donor
Page 11 and 12: Policy 2.11.B: Required Information
Page 17 and 18: Policy 6.1.A: Adult Heart Status 1A
Page 21 and 22: Policy 8.5.E: Allocation of Kidneys
Page 25 and 26: Policy 9.3.H: MELD/PELD Score Excep
Page 27 and 28: Policy 13.2: Potential KPD Donor Re
Page 35 and 36: Policy 14.4.B: Living Kidney Donor
Page 37 and 38: ⦁ Personal history of:⦁ Hyperte
Page 43: OPTN Member Evaluation PlanUpdated
Page 47 and 48: Policy 18.5.A: Reporting Requiremen
Page 49 and 50: Bylaws Appendix B.1: OPO Compliance
Page 51 and 52: Bylaws Appendix B.4: OPO PersonnelO
Page 55 and 56: Bylaws Appendix D.5: Transplant Pro
Page 57 and 58: Transplant hospitals must:Address e
Page 61 and 62: Bylaws Appendix D.10.A: Transplant
Page 63 and 64: Bylaws Appendix F.6.E: Conditional
Page 67 and 68: Bylaws Appendix K.4.A: Notice to th

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