This regulation requires Medicare-approved transplant programs to maintain emergency preparedness policies and procedures that are integrated into the hospital's overall emergency preparedness program. Transplant programs must participate in the hospital's risk assessment process to ensure transplant-specific risks are identified and addressed. Surveyors verify that such policies exist and are incorporated into the hospital's emergency plans.
View official sourceE-0005 (Rev. 200, Issued: 02-21-20; Effective: 02-21-20, Implementation: 02-21-20) §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.