E. A licensee of a
non-accredited procurement organization shall ensure that:
1. The procurement organization complies with
vital records requirements in A.R.S. §
36-325;
2. An identification system according to
A.R.S. §
36-851.03(A)(3)(b)
for donors:
a. Is established and maintained,
and
b. Assigns a unique
identification number according to A.R.S. §
36-851.03(A)(6)(a);
i. For each donor, and
ii. Used to identify all NAM from a donor
that is recovered and distributed;
3. SOPs are established, documented, and
implemented that includes:
a. Job
descriptions, duties, and qualifications, including required skills, knowledge,
education, and experience for technicians and personnel members;
b. Orientation and in-service education for
technicians and personnel members;
c. How a technician may submit a complaint
related to services provided;
d.
Donor records, including electronic records;
e. A quality management program, including
incident reports;
f. Ethical
practices;
g. An infectious control
program;
h. Security, including
evacuation procedures in the event of fire or disaster;
i. NTAD and NAM inventory controls;
and
j. Contracted
services;
4. SOPs for all
services and activities are established, documented, and implemented for:
a. The proper use and maintenance of a donor
consent form according to A.R.S. §
36-851.03(A)(3)(a);
b. Protocols and materials used to screen
end-users prior to release and transfer of NAM according to A.R.S. §
36-851.03(A)(3)(c);
c. Donor screening and testing plan,
including:
i. Acceptability
assessment,
ii. Donor risk
assessment,
iii. Medical records
review,
iv. Donor eligibility,
and
v. Infectious disease
testing;
d. Acquisition
of NTAD;
i. Donor verification;
ii. Donor identity;
iii. Acquisition records;
iv. Packaging, including packaging insert
form that discloses disease status of tissue to the end-user;
v. Labeling;
vi. Transport; and
vii. Storage;
e. Preparation methods, including:
i. Receipt of NAM;
ii. Prevent airborne transmission,
and
iii. Quarantine and storage, if
applicable;
f. Release
and transfer, including:
i. End-user
eligibility review;
ii. Quality
control review;
iii. Release of
NAM;
iv. Exceptional
release;
v. Failing review process;
and
vi. Transfer to distribution
for use, including out-of-state and international shipping;
g. Final disposition of donation
according to A.R.S. §
36-851.03(A)(3)(f)
and consistent with:
i. Board of Funeral Directors and Embalmers
specified in 4 A.A.C. 12, Articles 3, 5, and 6;
ii. Vital Records and Public Health
Statistics specified in A.R.S. Title 36, Chapter 3;
iii. Vital Records and Statistics specified
in 9 A.A.C. 19;
iv. Health menaces
specified in A.R.S. Title 36, Chapter 6, Article 1;
v. Disposition of Human Bodies specified in
A.R.S. Title 36, Chapter 7; and
vi.
Communicable Diseases and Infestations specified in 9 A.A.C. 6;
5. SOPs that all NTAD
acquired by the procurement organization shall bear a label that:
a. Is written, printed, or graphic material
used to identify NTAD/NAM, blood specimens, or other donor specimens;
and
b. States according to A.R.S. §
36-851.03(A)(6)(b):
i. The NTAD or NAM is not for transplant or
clinical use;
ii. Any condition and
any limitation regarding the use of the NTAD or NAM;
iii. That universal precautions shall be
used; and
iv. The contact
information for the procurement organization;
6. SOPs are:
a. Maintained at the procurement organization
and copies available to the Department for review upon request;
b. Reviewed at least once every three years
and updated as needed; and
c.
Available to technicians and personnel members; and
7. A loss or theft of NTAD or NAM is
documented and reported to the appropriate law enforcement agency within 24
hours of discovery.