Medicare Conditions of Participation

Working with Medicare

In an effort to increase organ, tissue, and eye donation, federal regulations formally established a collaborative working relationship between the OPOs, tissue/eye banks and hospitals. However, our hope is that we can work together with hospitals in the spirit of partnership rather than mandates. To this end, our staff work diligently and sensitively to ensure that our relationships are strong and the family and donation processes run smoothly.

The Routine Death Notification Legislation (42 CFR Part 482), part of the Code of Federal Regulations that govern acute care hospitals, is a condition for participation in the Medicare program. The highlights of the regulation are as follows:

  1. The hospital is to have written agreements with LifeNet Health and with at least one eye bank.
  2. The hospital is to notify LifeNet Health of every individual who has died or whose death is imminent, in a timely manner, before medical suitability is determined and before the family is given the option of donation. Timely is defined as within one hour of any imminent death trigger or within one hour of cardiac death.
  3. LifeNet Health determines the patient's medical suitability for organ and tissue donation.
  4. The eye bank determines the patient's medical suitability for eye donation.
  5. The hospital is to ensure—in collaboration with LifeNet Health and the eye bank—that each family of a potential donor is presented the option of donation. The individual designated to make the request to the family must be from LifeNet Health, the eye bank or a designated requestor. A designated requestor is an individual from the hospital who has completed a course approved by LifeNet Health and designed in conjunction with the Eye Bank.
  6. The hospital is to work cooperatively with LifeNet Health and the eye bank in educating staff on donation issues, reviewing death records to improve identification of potential donors, and maintaining potential donors while necessary testing and placement of potential donated organs, tissues and eyes takes place.

To access detailed questions on hospital conditions of participation for organ donation, visit the Centers for Medicare & Medicare Services website.