HospitalInspections.org

Based on observations and interview it was revealed the facility failed to follow West Virginia State dietetic service regulations. (Cross Reference CSR 7.3.o and CSR 7.3.t). This failure has the potential to cause harm to all patients.

Findings include:

1. A tour was conducted of the dietary department on 11/30/20 at 11:15 a.m. No food samples were observed in the refrigerators.

2. An interview was conducted on 11/30/20 at 11:15 a.m. with the Certified Dietary Manager (CDM). She revealed the facility does not provide an in-service program designed for dietary personnel.

3. An interview was conducted with the CDM on 11/30/20 at 1:00 p.m. She revealed food samples of meals served had not been kept for the twenty-four (24) hours prior to 11/30/20 at 1:00 p.m.

Based on physician credentialing file reviews, document review and interview it was revealed the governing body failed to re-appoint medical staff in accordance with its by-laws, rules and regulations. This failure was identified in two (2) out of three (3) credentialing file reviews (physician #1 and #2). This failure has the potential to place all patients at risk for an adverse event due to non-compliance with State licensure laws by medical staff.

Findings include:

1. A review of physician #1's credentialing file conducted on 12/02/20 revealed a lack of documented continuing education in the file.

2. A review of physician #2's credentialing file conducted on 12/02/20 revealed a lack of documented continuing education in the file.

3. A review of the "Bylaws, The Medical Staff Sistersville General Hospital, Sistersville, West Virginia" states in part: "The recommendations for reappointment will reflect both the academic and professional experience of the applicants and will include: ... Compliance with hospital and medical staff rules and bylaws ... Documentation of continuous medical education as required by the state licensure."

4. An interview was conducted on 12/02/20 at approximately 11:00 a.m. with the medical office clerk. When asked for the continuing education for physician #1 she stated in part: "Physician #3 has it and did not send it for filing." When asked for the continuing education for physician #2 she stated in part: "He couldn't find his certificates." When asked if the continuing education documentation is required to be filed in their credentialing files and if they have a policy, she stated in part: "They are not following the medical staff bylaws ... they must be sent to their files."

Based on observations, document review and interviews it was revealed the Clinical Nurse Manager (CNM) failed to ensure clinical staff maintained crash carts following policy and procedures to ensure drugs and biologicals used in life-saving procedures are readily available for emergency cases. This failure was identified in one (1) out of one (1) crash carts. This failure has the potential to place all patients at risk for lack of sufficient drugs and biologicals for emergency cases.

Findings include:

1. An observation was conducted on 11/30/20 at approximately 11:40 a.m. of the Acute/Extended Care (Swing Bed) unit. Review of the crash cart revealed a document titled "Monthly Crash Cart Checklist Emergency Room," revised 05/2020, was not completed each month from 01/2020 through 11/2020 checking the crash cart's supplies and medication inventory.

2. An observation was conducted on 11/30/20 at approximately 11:40 a.m. of the Acute/Extended Care (Swing Bed) unit. Review of the crash cart revealed a document untitled and undated with the year was not completed each month from May through December checking the medication inventory and from January through December checking the equipment and supplies.

3. A review of hospital policy "Crash Cart Integrity," revised 01/18, states in part: "There are three (3) crash carts available at Sistersville General Hospital for emergency situations. The crash carts are located in the following areas: Acute/Extended Care ... Emergency Room (ER), Computed Tomography (CT) room ... Nursing staff are responsible for the integrity of the crash carts. ... The defibrillators are to be checked by doing a discharge test and mounting the test strip for documentation. The CT room cart is to be checked regularly at a minimum of once a week by radiology staff. ... The appropriate check sheets will be completed to assure accuracy in Crash Cart integrity. ... Checks will be verified at random intervals by Nursing Administration staff, any deficiencies found will be addressed with the responsible staff."

4. An interview with the Chief Administrative Officer (CAO) was conducted on 11/30/20 at approximately 2:30 p.m. When asked about the incomplete monthly inventory checks on the crash carts, he concurred if not documented, it's not done.

5. An interview with the CNM was conducted on 11/30/20 at approximately 2:30 p.m. When asked about the lack of documented monthly crash cart and inventory checks, he concurred they should be documenting monthly checks by nursing and pharmacy.

A. Based on observation, document review and staff interview it revealed the Director of Nursing failed to ensure clinical staff monitor crash carts following policy and procedures to ensure equipment, supplies and medications are readily available for emergency cases. This failure was identified in three (3) out of three (3) crash carts. This failure has the potential to place all patients at risk for lack of sufficient supplies and equipment for emergency cases.

Findings include:

1. An observation was conducted on 11/30/20 at approximately 11:40 a.m. of the Acute/Extended Care (Swing bed) unit. The crash cart revealed a document titled "Monthly Crash Cart Checklist Emergency Room," revised 05/2020, was not completed each month from 01/2020 through 11/2020 checking the crash cart's supplies and medication inventory.

2. An observation was conducted on 11/30/20 at approximately 11:40 a.m. of the Acute/Extended Care (Swing bed) unit. Review of the crash cart revealed a document untitled and undated with the year, were not completed each month from May through December checking the medication inventory and from January through December checking the equipment and supplies.

3. A review of the Computed Tomography (CT) crash cart documentation revealed there was not any "Crash Cart Checklist" documenting inventory of the supplies and equipment.

4. A review of hospital policy, "Crash Cart Integrity," revised 01/18, states in part, "There are three crash carts available at Sistersville General Hospital for emergency situations. The crash carts are located in the following areas: Acute/Extended Care ... Emergency Room (ER), Computed Tomography (CT) room ... Nursing staff are responsible for the integrity of the crash carts. ... The defibrillators are to be checked by doing a discharge test and mounting the test strip for documentation. The CT room cart is to be checked regularly at a minimum of once a week by radiology staff. ... The appropriate check sheets will be completed to assure accuracy in Crash Cart integrity. ... Checks will be verified at random intervals by Nursing administration staff, any deficiencies found will be addressed with the responsible staff."

5. An interview with the Chief Administrative Officer was conducted on 11/30/20 at approximately 2:30 p.m. When asked about the incomplete monthly inventory checks on the crash carts, he concurred if not documented, it's not done.

6. An interview with the Clinical Nurse Manager was conducted on 11/30/20 at approximately 2:30 p.m. When asked about the lack of documented monthly crash cart and inventory checks, he concurred they should be documenting monthly checks by nursing and pharmacy.

7. An observation conducted on 11/30/20 at approximately 3:45 p.m. of the crash cart in the Emergency Department revealed a document titled "Monthly Crash Cart Checklist Emergency Room," revised 05/2020, was not completed each month from 01/2020 through 11/2020 checking the crash cart's equipment and supplies on the top of the cart, supplies in drawer #2 and supplies in drawer #3. Supplies in drawer #4, #5 and equipment and supplies on the side of the crash cart were not documented monthly checks from 09/2020 through 11/2020.

B. Based on observation, document review and staff interview it revealed the Director of Nursing failed to ensure clinical staff monitor the emergency room (ER) defibrillator in the overflow area following policy and procedures to ensure equipment, supplies and medications are readily available for emergency cases. This failure was identified in one (1) out of four (4) defibrillators. This failure has the potential to place all patients at risk for lack of sufficient supplies and equipment for emergency cases.

Findings include:

1. An observation conducted on 11/30/20 at approximately 3:45 p.m. of the ER overflow rooms revealed a defibrillator without daily documentation checking the equipment.

2. A review of hospital policy, "Crash Cart Integrity," revised 01/18, states in part, "The defibrillators are to be checked by doing a discharge test and mounting the test strip for documentation. ... Checks will be verified at random intervals by Nursing administration staff, any deficiencies found will be addressed with the responsible staff."

3. An interview with the Clinical Nurse Manager was conducted on 11/30/20 at approximately 3:45 p.m. When asked if the defibrillator in the ER overflow rooms was being checked, he stated in part, "We have not been checking it daily."
checking it daily."

Based on observation, document review and staff interview it revealed the Pharmacy Operations Manager failed to ensure Ativan vials are locked appropriately in the Acute/Extended Care Unit (Swing Bed) medication room refrigerator. This failure was identified in one (1) out of three (3) medication room observations. This failure has the potential to place the facility and nursing staff at risk for access to unsecured narcotic medications.

1. An observation conducted on 11/30/20 at approximately 11:40 a.m. of the Acute/Extended Care (Swing bed) unit revealed six (6) vials of Ativan 2mg/ml (milligrams per milliliter) single dose vials were stored in the medication room in an unlocked refrigerator. There was not any log for review of daily counts of the Ativan vials.

2. A review of hospital policy, "Controlled Substances," revised 03/09, states in part, "Drugs with high abuse potential are subject to special handling, storage, disposal and record keeping."

3. An interview was conducted on 12/01/20 at approximately 10:50 a.m. with the Pharmacy Operations Manager. When asked if the refrigerator in the Acute/Extended Care medication room needed to be locked and counted, he stated in part, "It does need to be locked and counted every day."

Based on observations, document review and interview it was revealed the facility failed to provide and monitor a clean and sanitary environment to minimize infectious agents in patient rooms of the Acute/Extended Care Unit. This failure was identified in three (3) out of five (5) patient rooms. This failure has the potential to place all patients and staff at risk for infection.

Findings include:

1. An observation conducted on 11/30/20 at approximately 12:15 p.m. revealed brown and yellow substances with pitting on sink drain covers in rooms 201, 205 and 206. The sink in room 206 has a white/yellow rough edging of caulk approximately one (1) inch thick around the perimeter of the bowl sealing it to the sink counter.

2. A review of hospital policy "Environmental Services," reviewed 02/08, states in part: "To control the spread of infection within the hospital by maintaining a thoroughly clean and safe environment. ... Environmental Services personnel shall report any equipment failure to Director of Environmental Services."

3. An interview was conducted with the Chief Administrative Officer, Clinical Nurse Manager and the Quality Improvement Coordinator on 12/02/20 at approximately 8:30 a.m. When asked if the rusted and pitted sink drains were not able to be properly disinfected and was a risk for infection, they concurred.

Based on observation, document review and staff interview it was revealed the facility failed to meet the provisions applicable to Critical Access Hospitals (CAH) of the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) 101. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census was zero (0).

Findings include:

1. In reference to Federal Life Safety Code citation K761 the facility failed to ensure that the fire doors assemblies were inspected and tested annually.

2. These findings were verified with the Facilities Maintenance Manager at the time of discovery and again with the Administrator at the time of exit.

Based on observations, document review and interview it was revealed the Pharmacy Operations Manager failed to ensure Ativan vials were stored and locked appropriately in the Acute/Extended Care Unit (Swing Bed) medication room refrigerator and accurate records were kept for disposition of the drug. This failure was identified in one (1) out of one (1) observation tour. This failure has the potential to place the facility at risk for unsecured narcotic medications.

Findings include:

1. An observation conducted on 11/30/20 at approximately 11:40 a.m. of the Acute/Extended Care (Swing Bed) Unit revealed six (6) vials of Ativan two (2) mg/ml (milligrams per milliliter) single dose vials were stored in the medication room in an unlocked refrigerator. There was not any log for review of daily counts of the Ativan vials.

2. A review of hospital policy, "Controlled Substances," revised 03/09, states in part: "Drugs with high abuse potential are subject to special handling, storage, disposal and record keeping."

3. An interview was conducted on 12/01/20 at approximately 10:50 a.m. with the Pharmacy Operations Manager. When asked if the refrigerator in the Acute/Extended Care medication room needed to be locked and counted he stated in part, "It does need to be locked and counted every day."

Based on clinical record review, document review and interview it was revealed three (3) out of three (3) patients (pt #15, 17 and 19) did not have a plan of care that included goals, treatment type, amount, frequency and duration of services (which could be revised as needed). This failure could create the potential that treatment will be provided inconsistently placing patients at risk for harm or injury.

Findings include:

1. A review of patient #15's clinical record revealed she started physical therapy on 9/2/20 for low back pain. Her plan of care did not include the amount, frequency and duration of services.

2. A review of patient #17's clinical record revealed he started physical therapy on 9/2/20 for low back pain. His clinical record did not include a plan of care.

3. A review of patient #19's clinical record revealed she started physical therapy on 9/21/20 for a partial tear in her anterior cruciate ligament. Her plan of care did not include treatment type, amount, frequency and duration of services.

4. A review of a document titled "SUBJECT: STANDARDS OF PRACTICE... DEPARTMENT; PHYSICAL THERAPY," effective date 1/18/08, revealed it stated in part: "Responsibilities of Departmental Director ... Ensure that the departmental objectives are efficiently conducted ... in accordance with current standards of rehabilitation medicine."

5. A review of a document titled "SUBJECT: PATIENT REFERRALS...DEPARTMENT: PHYSICAL THERAPY," effective date 1/18/08, revealed it stated in part, "These services (rehabilitation therapy) are provided under a written treatment program that is regularly evaluated."

6. A review of a document titled "SUBJECT: OBJECTIVES...DEPARTMENT: PHYSICAL THERAPY," effective date 1/18/08, revealed it stated in part, "The Rehabilitation Services Department staff will develop and support a plan of care to foster the most comprehensive and effective patient care, thus leading to the greatest patient outcome."

7. An interview was conducted on 12/2/20 at 3:35 p.m. with the Physical Therapy Supervisor. He revealed the individual physical therapy plans do not list type, amount, frequency and duration of services. He stated he relies on each physical therapist to decide what treatment is provided from a list of possible treatments. He concurred not having an individualized plan of care creates the possibility patients could be harmed by inconsistent care.

A. Based on clinical record review, document review and interview it was revealed the facility failed to ensure the completed clinical record for patient #5 contained the death certificate. This failure was identified in one (1) out of two (2) death records reviewed. This failure has the potential to place all patients at risk for an adverse event due to incomplete and inaccurate clinical records.

Findings include:

1. A review of patient #5's clinical record dated 07/18/20 revealed the certificate of death was not in the record.

2. A review of hospital policy, "Functions of the Medical Record Department," reviewed 09/06/08, states in part: "The medical record shall be a complete case history or written report for each patient. This record will include: ... consultations, and other specified reports ...."

3. A review of hospital policy "Delinquent Records," revised 09/05/18, states in part: "It is the policy of Sistersville General Hospital that a completed medical record should include: ... other specified reports ...."

4. An interview was conducted on 12/01/20 at approximately 3:30 p.m. with the Quality Improvement Coordinator. When asked for patient #5's death certificate she stated in part, "We don't have it." When asked if it is part of the clinical record she stated in part, "We consider it to be included in the record. It is part of the completed record."

B. Based on clinical record review, document review and interview it was revealed the facility failed to ensure the emergency room (ER) clinical record for patient #20 was complete and accurately documented. This failure was identified in one (1) out of five (5) emergency room clinical record reviews. This failure has the potential to place all patients at risk for an adverse event due to incomplete and inaccurate clinical records.

Findings include:

1. A review of patient #20's clinical record dated 09/01/20 revealed the ER flow sheet and an Against Medical Advice form.

2. A review of hospital policy "Functions of the Medical Record Department," reviewed 09/06/08, states in part: "The medical record shall be a complete case history or written report for each patient. This record will include: ... consent forms ... results of physical exam ... consultations, and other specified reports ...."

3. A review of hospital policy "Delinquent Records," revised 09/05/18, states in part: "It is the policy of Sistersville General Hospital that a completed medical record should include: ... consent forms ... results of physical exam ... other specified reports ... nurses notes ...."

4. A review of hospital policy,"Patient leaving AMA/LWOT" (Against Medical Advice/Left Without Treatment), reviewed 08/07, states in part: "Procedure: ... Notify the physician of the patient's decision, to inform patient of possible medical consequences of their actions. Request that the patient sign the "AMA" form and that it is witnessed. ... Document a detailed description of all events surrounding the event, including the signing of the form and notification of physician, family, charge nurse ... Any comments that the patient may have made prior to leaving should be documented. ... If the patient refuses to sign the form, document the same and if possible, obtain signatures of witnesses. ..."

5. An interview was conducted on 12/02/20 at approximately 2:20 p.m. with the Quality Improvement Coordinator. When asked if Registered Nurse (RN) #1 should have completed a ER triage form with a note of the patient's mental health status, a detailed note of reason for refusing treatment and have the physician sign off she stated in part, "I would expect the nurse to have completed a triage form and document what happened and signed off by the doctor."

6. An interview was conducted on 12/02/20 at approximately 3:30 p.m. with RN #1. When asked about a lack of documentation of patient #20's mental status, details of the patient refusing treatment, no AMA form and physician signing the documents he stated in part, "The patient was brought in by his caregivers and friends without his consent. ... I could have had documented he was oriented and documented he refused to fill out the AMA form."

Based on observation, document review and interview it was revealed the facility failed to implement nationally recognized program guidelines for preventing Coronavirus 19 (COVID 19) spread. COVID 19 is a respiratory virus which was declared a pandemic in March 2020. The disease is passed through respiratory droplets. This failure has the potential to place all patients at risk for harm or death from contracting a communicable disease.

Findings include:

1. On entry into the facility 11/30/20 at 9:55 a.m. the surveyors noted the facility did not post signs with instructions to individuals entering the facility on how to observe good respiratory hygiene practices (cover nose and mouth when coughing or sneezing, use and dispose of tissues and perform frequent hand hygiene using soap or hand sanitizer). There were no signs at the Emergency Department (ED) entrance describing the signs and symptoms of COVID as per the Centers for Disease Control (CDC) guidelines.

2. Review of a document titled "CDC (Centers for Disease Control) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," updated 11/4/2020, revealed it states in part: "Take steps to ensure that everyone adheres to source control measures and hand hygiene practices while in a healthcare facility. Post visual alerts (e.g. signs, posters) at the entrance and in strategic places (e.g. waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about wearing a cloth face covering or facemask for source control and how and when to perform hand hygiene."

3. An interview was conducted on 12/1/20 at 12:05 p.m. with the Infection Control Registered Nurse. She revealed the facility follows CDC guidelines to prevent the spread of COVID 19. She stated the facility used to have posted signage instructing staff, visitors and patients on good respiratory hygiene to prevent the spread of disease. She acknowledged there were no posted signage of signs and symptoms of COVID-19 as recognized by the CDC. She acknowledged posted signage as described above was not in place at the ED entrance neither on 11/30/20 at 9:55 a.m. nor 12/1/20 at 8:15 a.m.

Based on document review and interviews it was revealed the facility failed to ensure written protocols were in place for organ procurement. The facility failed to designate a member of their staff to act as a requestor. The facility failed to provide training for a requestor. The facility failed to work cooperatively with the Organ Procurement Organization (OPO)-Center for Organ Recovery and Education (CORE) to ensure all patient care staff are educated on donation issues including sensitivity training. The facility failed to develop policies and procedures for preservation of the body. The facility failed to incorporate the means of notification of the OPO in their policy and contract. This failure places all patients at risk to have their wishes for organ donation mishandled. (See Tags C 1503, C 1507, C 1509 and C 1511).

Based on document review and interview it was revealed the facility failed to ensure their contract with the Center for Organ Recovery and Education (CORE) included provisions for training of facility staff to be requestors. This failure has the potential to place all patients at risk for mishandling of their wishes for donation.

Findings include:

1. Review of facility documents related to death and organ donation revealed the facility does not have policies and procedures addressing their organ procurement responsibilities.

2. Review of a document titled "STATEMENT OF AGREEMENT BETWEEN Sistersville General Hospital and CENTER FOR ORGAN RECOVERY & EDUCATION" dated 7/26/16 revealed it states in part: "Duties of CORE ...Work with the Donor Hospital staff to facilitate all aspects of organ and tissue donation including the development of policies and procedures ..." The document further states CORE assumes the role of requestor. The document states in part: "CORE will offer sensitivity training at the request of Hospital Senior Leaders." The document states in part: "Duties of the Donor Hospital ... Adopt and implement written protocols or policies that meet the requirements of state and federal law and regulations concerning organ, tissue and eye donation programs and procedures ... Ensure Donor Hospital staff participation as appropriate in training provided by CORE ... Provide training on donation issues, developed in cooperation with CORE to all patient care staff and/or staff that will work with CORE. Training should promote discretion and sensitivity with respect to the circumstances, views, beliefs and desires of the families of potential donors."

2. A group interview was conducted on 12/1/20 at 8:55 a.m. with the Director of Nurses, the Chief Executive Officer and the Quality Improvement (QI) Registered Nurse (RN). They revealed the facility does not have staff filling the role of a designated requestor. They stated the facility does not provide sensitivity training to their staff. They stated CORE does not provide organ procurement training, including sensitivity training, to staff. The QI RN reviewed the facility's policies and procedures related to patient death. She concurred there are no organ donation policies relating to care of the potential donor's body. The group of interviewees acknowledged there are no policies addressing designation of and education of a requestor with a list of his/her duties. The group agreed they were not aware policies related to organ transplantation had to be developed with CORE as mandated by federal regulations.

Based on document review and interview it was revealed the facility failed to ensure their contract with the Center for Organ Recovery and Education (CORE) included provisions for training of facility staff to be requestors. This failure has the potential to place all patients at risk for mishandling of their wishes for donation.

Findings include:

1. Review of facility documents related to death and organ donation revealed the facility does not have policies and procedures addressing their organ procurement responsibilities.

2. Review of a document titled "STATEMENT OF AGREEMENT BETWEEN Sistersville General Hospital and CENTER FOR ORGAN RECOVERY & EDUCATION" dated 7/26/16 revealed it states in part: "Duties of CORE ...Work with the Donor Hospital staff to facilitate all aspects of organ and tissue donation including the development of policies and procedures ..." The document further states CORE assumes the role of requestor. The document states in part: "CORE will offer sensitivity training at the request of Hospital Senior Leaders." The document states in part: "Duties of the Donor Hospital ... Adopt and implement written protocols or policies that meet the requirements of state and federal law and regulations concerning organ, tissue and eye donation programs and procedures ... Ensure Donor Hospital staff participation as appropriate in training provided by CORE ... Provide training on donation issues, developed in cooperation with CORE to all patient care staff and/or staff that will work with CORE. Training should promote discretion and sensitivity with respect to the circumstances, views, beliefs and desires of the families of potential donors."

3. A group interview was conducted on 12/1/20 at 8:55 a.m. with the Director of Nurses, the Chief Executive Officer and the Quality Improvement (QI) Registered Nurse (RN). They revealed the facility does not have staff filling the role of a designated requestor. They stated neither the facility nor CORE provide organ donation education to their staff. The QI RN reviewed the facility's policies and procedures related to organ donation. She concurred there are no organ donation policies relating to education of staff on organ donation, nor designation of a trained requestor with a list of his/her duties. The group agreed they were not aware policies related to organ transplantation had to be developed with CORE as mandated by Federal Regulations..

A review of documents and interviews revealed the facility failed to provide patient care staff with sensitivity training. This training is intended to ensure discretion and sensitivity are used in consideration of the circumstances and in keeping with the patient and families views and beliefs. This failure has the potential to harm all patients who are potential donors and their families.

Findings include:

1. A review of policies and procedures provided to the surveyors as those pertaining to death of the patient revealed there were no policies or procedures for education of staff on organ procurement. There were no policies and procedures for interacting with families of potential donors. There were no policies and procedures for designation of a trained educated requestor.

2. A group interview was conducted on 12/1/20 at 8:55 a.m. with the Director of Nurses, the Chief Executive Officer and the Quality Improvement (QI) Registered Nurse (RN). They revealed the facility does not have a designated requestor. They stated neither the facility nor the Center for Organ Recovery and Education (CORE), their Organ Procurement Organization, provides sensitivity training to their staff. The QI RN reviewed the facility's policies and procedures related to patient death in relation to organ donation. She concurred there are no organ donation policies relating to sensitivity training and education of staff or designation of a trained requestor with a list of his/her duties. The group agreed they were not aware policies and procedures related to organ transplantation had to be developed with CORE as mandated by federal regulations.

A review of documents and interviews revealed the facility failed to ensure all patient care staff are educated on organ donation issues and how to contact and work with their organ procurement organization, the Center for Organ Recovery and Education (CORE). This failure has the potential to harm all patients who are potential donors and their families.

1. A review of documents revealed there was no policy and procedure for training of patient care staff on organ donation issues.

2. A group interview was conducted on 12/1/20 at 8:55 a.m. with the Director of Nurses, the Chief Executive Officer and the Quality Improvement (QI) Registered Nurse (RN). They revealed neither the facility nor CORE, their Organ Procurement Organization, provide sensitivity training to the facility's patient care staff. The QI RN reviewed the facility's policies and procedures related to death of a potential donor. She concurred there are no organ donation policies and procedures. The group agreed they were not aware policies related to organ transplantation had to be developed with CORE as mandated by federal regulations..