Section 7158.1 Of Chapter 3.55. Organ And Tissue Donation Information And Procedures From California Health And Safety Code >> Division 7. >> Part 1. >> Chapter 3.55.
7158.1
. (a) As a part of its ongoing audit and review process, the
Licensing and Certification Division of the State Department of
Health Services shall audit for the existence of organ and tissue
procurement procedures for all inpatient hospital facilities. The
audit shall include a determination of whether these procedures are
in place in the facility, whether the procedures are operational and
functioning, and whether the procedures are being used. The
department shall not be required to audit for the effectiveness of
the procedures. No additional audits shall be required for purposes
of this section. Instead, the department shall add an organ and
tissue audit element to its regular ongoing audits of inpatient
facilities.
(b) For purposes of this chapter, "organ and tissue procurement
procedures" shall include protocols required to be developed pursuant
to Section 7184. The audit criteria shall, at a minimum, include all
of the following:
(1) That the protocols have been developed.
(2) That the protocols are operational.
(3) That notification requirements to next of kin or other
individuals as set forth in Section 7151 and to organ procurement
organizations are within a timeframe that is consistent with the
maintenance of the organs for the purpose of transplantation.
(c) The absence of any of the required organ and tissue
procurement procedures at any facility shall be noted by the
division, and included in a written audit report or site review
summary. In the event that an audit or facility review is conducted
in conjunction with review by a national accreditation agency, and
that agency prepares a report, the department shall request that the
information required by this section with respect to organ and tissue
procurement procedures be included in the report prepared by the
national accreditation agency. In this event, the department shall
not be required to prepare a separate report.