Main Body
Subpart 58-5
Regulatory Affairs - Statute and Regulations
Effective July 21, 2004
Subpart 58-5
Hematopoietic Progenitor Cell Banks
Statutory Authority: Public Health Law, section 3121(5)
Section
Definitions
General requirements
Hematopoietic progenitor cell procurement
Donor qualifications
Sterilization of instruments
Collection and handling of hematopoietic progenitor
cells
Section 58-5.1 Definitions.
As used in this Part:
(a) Bone marrow means the human tissue filling
cavities of bone, consisting of fully mature and precursor
hematopoietic cells intended for transplantation.
(b) Hematopoietic progenitor cells means human
precursor hematopoietic cells derived from bone marrow,
peripheral blood or other tissue sources, such as cord
blood obtained from the placenta or umbilical cord.
(c) Hematopoietic progenitor cell bank means
hematopoietic progenitor cell procurement service,
hematopoietic progenitor cell processing facility or
hematopoietic progenitor cell transplantation facility.
(d) Hematopoietic progenitor cell procurement
service means a facility which performs donor
selection and bone marrow aspiration or other hematopoietic
progenitor cell collection, and pre-processing storage of
hematopoietic progenitor cells from autogeneic and/or
allogeneic donors.
(e) Hematopoietic progenitor cell processing
facility means a facility which processes bone
marrow or other hematopoietic progenitor cell samples,
including purging, storage, and distribution of
hematopoietic progenitor cells from autogeneic and/or
allogeneic donors.
(f) Hematopoietic progenitor cell transplantation
facility means a facility which temporarily stores
and transplants hematopoietic progenitor cells, and
includes facilities which infuse autogeneic
hematopoietic progenitor cells and bone marrow
transplantation services approved by the commissioner
pursuant to section 709.8 of this Title.
(g) Hematopoietic progenitor cell transplantation
service means a specific unit conducting
hematopoietic progenitor cell transplantation within a
hematopoietic progenitor cell transplantation facility.
Such a service shall be independently supervised by a
qualified director.
(h) Department means the New York State
Department of Health.
(i) Commissioner means the Commissioner of the
New York State Department of Health.
58-5.2 General requirements.
(a) A hematopoietic progenitor cell procurement service
shall possess a license issued under Subpart 52-2 of
this Title in the category of either limited tissue
procurement service or comprehensive tissue procurement
service, and operate under standards established by
this Subpart, Subpart 52-2 except section 52-2.9, and
one or more licensed hematopoietic progenitor cell
transplantation facilities. Unless the procurement
service and the transplantation facility are operated
by the same institution, a hematopoietic progenitor
cell procurement service shall have a written agreement
with the transplantation facility, which specifies that
hematopoietic progenitor cells collected and stored by
the hematopoietic progenitor cell procurement service
are acceptable for transplantation by the hematopoietic
progenitor cell transplantation facility. Collection of
hematopoietic progenitor cells performed at facilities
outside New York State shall follow policies and
procedures consistent with this Subpart. Documentation
of such policies and procedures shall be maintained by
each associated hematopoietic progenitor cell
transplantation facility. Hematopoietic progenitor
cells collected outside New York State shall be
approved for use in New York State, in writing, by the
director of the hematopoietic progenitor cell
transplantation facility or by a physician designated
by the director.
(b) A hematopoietic progenitor cell processing facility
shall possess a license issued under Subpart 52-2 of
this Title in the category of tissue processing
facility, and be associated with and operating under
standards established by one or more licensed
hematopoietic progenitor cell transplantation services.
(c) A hematopoietic progenitor cell transplantation
facility shall possess a license issued under Subpart
52-2 of this Title in the category of tissue
transplantation facility.
(d) Hematopoietic progenitor cell procurement services,
hematopoietic progenitor cell processing facilities and
hematopoietic progenitor cell transplantation
facilities may operate independently, or together as
part of the same organization.
(e) The director of a hematopoietic progenitor cell
procurement service and/or processing facility shall
ensure the development and implementation of policies
and procedures consistent with this Subpart for the
operation of the service and the appointment of a
medical director and a medical advisory committee.
(1) The director of a hematopoietic progenitor cell
procurement service collecting hematopoietic progenitor
cells from peripheral blood shall be a physician and
have at least one year's experience in apheresis,
including or supplemented by experience in the
performance or supervision of at least twenty-five (25)
peripheral blood hematopoietic progenitor cell
collection procedures. The director of a hematopoietic
progenitor cell procurement service collecting bone
marrow shall be a physician and have at least one
year's experience in bone marrow collection,
including or supplemented by experience in the
performance or supervision of at least twelve (12) bone
marrow collection procedures. The director of a
hematopoietic progenitor cell procurement service
collecting cord blood only shall be a physician and
have at least one year's experience in
hematopoietic progenitor cell collection, including or
supplemented by experience in the performance or
supervision of at least twenty-five (25) hematopoietic
progenitor cell collection procedures. Such director
shall also demonstrate satisfactory knowledge in the
area of hematopoietic progenitor cell collection, with
particular emphasis on the unique characteristics of
cord blood collection. A person who has been approved
by the department to direct a hematopoietic progenitor
cell procurement service as of the effective date of
these amendments shall be deemed to qualify as
director.
(2) The director of a hematopoietic progenitor cell
processing facility shall possess a doctoral degree in
the biological sciences and have at least three (3)
years' laboratory experience, including at least
six (6) months' experience in a clinical laboratory
or blood bank. In addition, the director of a
hematopoietic progenitor cell processing facility shall
have one year's experience in hematopoietic
progenitor cell processing, including or supplemented
by experience in the performance or supervision of at
least twenty-five (25) hematopoietic progenitor cell
processing procedures. A person who has been approved
by the department to direct a hematopoietic progenitor
cell processing facility as of the effective date of
these amendments shall be deemed to qualify as
director.
(f) Medical direction of a hematopoietic progenitor
cell procurement service and/or processing facility
shall be provided by a physician in consultation with
the medical advisory committee. Such physician shall be
licensed and currently registered with the New York
State Education Department or in the state or
jurisdiction of practice. The medical director of a
hematopoietic progenitor cell procurement service shall
have two (2) years' experience or training in
clinical hematology/oncology that includes experience
in bone marrow transplantation or two (2) years'
experience or training in transfusion medicine, in
addition to either one year's experience in
hematopoietic progenitor cell collection, or
performance or supervision of at least twenty-five (25)
hematopoietic progenitor cell collection procedures for
each anatomic site (bone marrow, peripheral blood, cord
blood or other site) to be used as a source of
hematopoietic progenitor cells. The medical director of
a hematopoietic progenitor cell processing facility
shall have two (2) years' experience in clinical
hematology/oncology that includes bone marrow
transplantation experience, or two (2) years'
experience or training in laboratory medicine or
transfusion medicine, in addition to either one
year's experience in hematopoietic progenitor cell
processing, or experience in the performance or
supervision of at least twenty-five (25) hematopoietic
progenitor cell processing procedures. A person who has
been approved by the department as medical director of
a hematopoietic progenitor cell bank as of the
effective date of these amendments shall be deemed to
qualify as medical director.
(g) The hematopoietic progenitor cell transplantation
service director shall be a physician who shall be
responsible for compliance with section 52-2.8 of this
Title, and shall monitor the medical efficacy of the
hematopoietic progenitor cell transplantation program.
(h) The medical advisory committee, which may be the
in-house transfusion committee or transplantation
committee, shall include experts in the areas of
infectious disease, hematology, oncology,
histocompatibility and transfusion medicine, as well as
physicians representing associated hematopoietic
progenitor cell transplantation facilities. The
committee shall meet at least annually.
(i) The medical director of a hematopoietic progenitor
cell procurement service, in consultation with the
medical advisory committee shall monitor the medical
efficacy of the program, and in conjunction with the
associated hematopoietic progenitor cell
transplantation facility shall, as a minimum, develop
medical criteria for donor participation.
(j) The medical director of a hematopoietic progenitor
cell procurement service shall be responsible for all
aspects of donor qualification, as described in section
58-5.4 of this Subpart.
(k) The director of a hematopoietic progenitor cell
procurement service and/or processing facility shall be
responsible for the technical and scientific operation
of the facility, and shall develop quality standards
for hematopoietic progenitor cells.
58-5.3 Hematopoietic progenitor cell procurement.
(a) Facilities where allogeneic or autogeneic
hematopoietic progenitor cells are collected shall be
adequately lighted, ventilated and equipped, and be
operated in a manner which conforms to current medical
standards generally accepted by leading authorities in
transplantation medicine.
(b) Each hematopoietic progenitor cell procurement
service, except for such facilities collecting cord
blood only, shall document association with a
hematopoietic progenitor cell transplantation facility
and compliance with the procedures, protocols and
record keeping requirements for collection as
established by the transplantation facility, as well as
all requirements of this Subpart.
(c) All required clinical laboratory testing shall meet
the standards of Article 5, Title V of the Public
Health Law.
(d) For bone marrow harvesting procedures, adequate
facilities shall be available for the administration of
anesthesia and for emergency resuscitation. A qualified
anesthesiologist shall be on the premises at all times
during harvesting procedures.
(e) Emergency services shall be immediately available
to any donor who manifests an adverse reaction.
(f) A physician shall explain the hazards of the
donation procedure to the donor in such a manner that
the donor is offered an opportunity to refuse consent.
The donor shall be advised of the risks of
hematopoietic progenitor cell donation and of the
anesthesia method to be used, the potential need for
transfusional support and possible side effects of each
procedure, and options for disposition of hematopoietic
progenitor cells no longer needed by the intended
recipient. All this information shall be provided to
each prospective donor in written form. The written
informed consent of the prospective donor shall then be
obtained. Autogeneic donors shall also be informed of
the risks associated with hematopoietic progenitor cell
collection.
(g) Informed consent for collection of cord blood shall
be obtained from the donor's mother before stem
cells are placed in inventory. In all cases of in
utero cord blood collection, consent shall be
obtained prior to collection.
(h) Hematopoietic progenitor cells from autogeneic
donors shall not be destroyed or released for purposes
other than infusion into the intended patient without
written authorization from the director of the facility
storing the hematopoietic progenitor cells and:
(1) if the donor/patient is deceased, written
documentation of death; or
(2) if the donor/patient is living, written
authorization from the physician currently responsible
for treating the patient for the underlying disorder
for which the hematopoietic progenitor cells were
collected; and documented informed consent from the
donor/patient or donor/patient's guardian, unless
it is documented that no response was received within
sixty (60) days to at least two (2) written requests
for such consent sent at least thirty (30) days apart.
Documentation of such written requests shall be
maintained.
(i) Hematopoietic progenitor cells from allogeneic
donors shall not be destroyed or released for purposes
other than transplantation into the originally intended
recipient without the written authorization of the
intended recipient's physician and documentation
that the intended recipient, if living, has been
notified that the cells will not be available.
58-5.4 Donor qualifications.
(a) Except in the case of an autogeneic donation, a
complete donor history shall be obtained prior to
hematopoietic progenitor cell donation. A summary of
the donor history obtained by a hematopoietic
progenitor cell procurement service shall be provided
to the physician performing the transplant for a
determination of the cells' suitability for
transplantation. The donor history, or in the case of
cord blood donation, the history of the donor's
biologic mother and, if available, the donor's
biologic father, shall include, but not be limited to,
information concerning:
(1) any acute respiratory disease;
(2) any infectious skin disease that creates a risk of
contamination of the hematopoietic progenitor cells;
(3) any disease transmissible by hematopoietic
progenitor cells insofar as can be determined by donor
history;
(4) active tuberculosis or history of therapy
therefore;
(5) history of malaria or travel to or residence in
malarially endemic areas for periods of time considered
to bear increased risks for malaria exposure, as
determined by criteria established by the procurement
or collection facility, consistent with criteria
developed by the United States Public Health Service;
(6) known coagulation or platelet disorders;
(7) any medical condition which may be affected
adversely by the collection procedure;
(8) any medical condition, including a malignancy, that
would adversely affect the quality of hematopoietic
progenitor cells collected;
(9) receipt of an organ transplant or a transfusion of
blood or blood components within the past twelve (12)
months;
(10) indications of drug or alcohol abuse; and
(11) other medical conditions or circumstances as
determined by the medical advisory committee and
medical director of the procurement service.
(b) Except in the case of an autogeneic donation or
cord blood donation, a complete physical examination of
the donor shall be performed by the medical director of
the procurement service or another qualified physician.
(c) For autogeneic donations, testing for syphilis,
hepatitis B surface antigen (HBsAg), antibody to human
immunodeficiency virus type 1 (anti-HIV-1) and antibody
to human immunodeficiency virus type 2 (anti-HIV-2)
shall be performed, unless already performed within the
previous thirty (30) days, or unless the hematopoietic
progenitor cells are collected, processed and
transfused at the same facility and a system is in
place to ensure disposition to the intended recipient.
(d) For allogeneic hematopoietic progenitor cell
donations in New York State, specimens of blood shall
be collected from the donor, or in the case of
umbilical cord blood, from the donor's mother, and
the following tests shall be performed in a clinical
laboratory under permit by the department. For
out-of-state donations, all required clinical
laboratory testing shall be performed by a laboratory
which is approved by the regulatory authority in the
state or jurisdiction where the laboratory is located,
or by the department:
(1) within thirty (30) days prior to or seventy-two
(72) hours after donation, and prior to initiation of
the transplant conditioning regimen in the recipient:
(i) direct tests for indicators of infection with
syphilis and cytomegalovirus (CMV);
(ii) HBsAg;
(iii) antibody to hepatitis B core antigen (anti-HBc),
antibody to hepatitis C virus (anti-HCV), anti-HIV-1,
anti-HIV-2, and antibody to human T-cell lymphotropic
virus type I (anti-HTLV-I); and
(iv) except for cord blood donation, peripheral blood
cell enumeration (red, white and platelet) and
differential blood smear evaluation.
(2) prior to ablation of the recipient, major
histocompatibility antigens (HLA-A, B and DR) and other
minor histocompatibility antigens, including mixed
lymphocyte culture or DNA typing, as indicated.
(e) Except for allogeneic donors confirmed positive for
any indicator of HIV infection, the decision as to the
acceptability of hematopoietic progenitor cells shall
be made by the hematopoietic progenitor cell
transplantation service director. Hematopoietic
progenitor cells from allogeneic donors confirmed
positive for any indicator of HIV infection may not be
used in any case.
58-5.5 Sterilization of instruments.
Syringes, needles, lancets, or other phlebotomy or
hematopoietic progenitor cell collection devices
capable of transmitting infection from one person to
another and licensed for single use by the Food and
Drug Administration shall be appropriately discarded
after such use. Reusable devices shall be
heat-sterilized prior to each use. Heat sterilization
shall be by autoclaving at 121.5 degrees Celsius for
fifteen (15) minutes after the chamber of the autoclave
has been evacuated and has reached that temperature, or
by dry heat for two (2) hours at 170 degrees Celsius,
or by such other similarly acceptable procedure in
accordance with current medical standards generally
accepted by leading authorities in transplantation
medicine.
58-5.6 Collection and handling of hematopoietic progenitor cells.
(a) All hematopoietic progenitor cell specimens
obtained by bone marrow aspiration shall be collected
by the medical director of the procurement service or
other qualified physician, physician's assistant,
or a nurse practitioner under the supervision of the
medical director. Hematopoietic progenitor cells
obtained by peripheral blood apheresis shall be
collected by an individual trained in pheresis in
accordance with the requirements of section 58-2.15 of
this Part. Cord blood collection shall be performed by
staff with documented training, experience and
proficiency in the techniques utilized.
(b) Hematopoietic progenitor cell collection apparatus
and containers shall be clean, pyrogen-free and
sterile.
(c) Phlebotomy and bone marrow aspiration puncture
sites shall be prepared by a procedure which conforms
to current medical standards generally accepted by
leading authorities in transplantation medicine.
(d) Hematopoietic progenitor cell collection systems
shall meet the following minimum requirements:
(1) hematopoietic progenitor cells shall be collected
under aseptic conditions using an approved system
adequately protected against contamination;
(2) additives shall be used as required to ensure the
continued suitability of hematopoietic progenitor cells
for transplantation and retention of viability. All
changes in additives shall be validated on-site, and
such validation shall be documented;
(3) each container shall be legibly labeled or tagged
at the time of collection with:
(i) the donor's identification code and date of
collection; and
(ii) if known, the recipient/patient's name, the
name of the hospital where the patient is to be
transplanted, and the patient's hospital
registration number, Social Security number, birth date
or similar identifying information;
(4) each final container shall be legibly labeled or
tagged at the time of issuance with:
(i) if performed, the results of laboratory tests for
syphilis, HBsAg, and antibodies to HBV, HCV, HIV-1,
HIV-2, HTLV-I and CMV, unless the results were
forwarded to the hematopoietic progenitor cell
transplantation service in advance or included in
records accompanying the hematopoietic progenitor
cells; and
(ii) a biohazard label, if the donor has tested
reactive or positive for any of the tests required in
section 58-5.4(c) or (d)(1) of this Subpart; and
(5) if microbial culturing is performed, suspected
contamination shall be reported to the transplantation
service.
(e) Prior to collection of cord blood, an access
agreement/acknowledgment shall be consummated between
the administration of the hospital or other collection
site and the licensed cord blood bank.
58-5.7 Hematopoietic progenitor cell processing facilities.
(a) If hematopoietic progenitor cells are to be frozen,
the following requirements apply:
(1) unless otherwise specifically authorized in writing
by the director of the hematopoietic progenitor cell
processing facility, hematopoietic progenitor cells
shall be frozen within forty-eight (48) hours of
collection using cryopreservation techniques generally
accepted by experts in transplantation medicine and
meeting the requirements of this Subpart;
(2) until used, hematopoietic progenitor cells shall be
stored continuously within a temperature range of minus
196 degrees Celsius to minus 80 degrees Celsius, under
one of the following conditions:
(i) in a mechanical freezer reserved for hematopoietic
progenitor cells, equipped with an automatic
temperature recording device, an audible alarm and a
back-up system in the event of unexpected mechanical
failure; or
(ii) in a liquid nitrogen freezer reserved for
hematopoietic progenitor cells, equipped with an
automatic liquid nitrogen level monitor, an audible
alarm and a back-up system in the event of unexpected
liquid nitrogen loss;
(3) frozen hematopoietic progenitor cells in transit
from a processing facility to a transplantation
facility or other facility shall be:
(i) maintained, at a minimum, on dry ice or in a liquid
nitrogen dry shipper. Storage/transport procedures for
the frozen hematopoietic progenitor cells shall be
validated, and such validation shall be documented;
(ii) transported as fast as reasonably possible and
without any unnecessary delay; and
(iii) used immediately upon arrival or stored as
required in paragraph (2) of this subdivision until
thawed for use; and
(4) hematopoietic progenitor cell specimens shall be
inspected visually at the time of freezing and thawing.
If the color or physical appearance is abnormal, the
cells shall not be released for transplantation unless
authorized, in writing, by the transplantation service
director.
(b) Hematopoietic progenitor cells stored in the liquid
state shall be maintained at a temperature and for a
period of time specified in a protocol approved by the
director of the hematopoietic progenitor cell
procurement service and/or processing facility.
(c) Storage temperature records for hematopoietic
progenitor cells shall be maintained as required in
section 58- 5.8(c) and (d) of this Subpart, and be made
available for inspection by the department for the
entire period of storage and for one year afterward.
(d) Unless needed to meet a medical emergency,
hematopoietic progenitor cells shall be transported in
a leak-resistant, crush-resistant and
puncture-resistant container featuring a prominent
label which:
(1) identifies the contents as "human blood,"
"human hematopoietic progenitor cells" or
"human bone marrow";
(2) describes the contents, the packing agent, if any,
and any special precautions necessary in handling such
contents; and
(3) contains the name, address and twenty-four (24)
hour telephone number of the person or entity to be
contacted in the event that the container is found
leaking or damaged, or is misdirected.
58-5.8 Required records.
(a) Complete and accurate records of hematopoietic
progenitor cells released for transplantation shall be
kept for seven (7) years by the hematopoietic
progenitor cell procurement service, processing
facility and transplantation service using the sample.
Such records shall be open to inspection by the
department. For all donated hematopoietic progenitor
cells, the donor's name, address, and any other
information that would directly or indirectly identify
the donor shall not be disclosed or released by the
bank to any person or entity, except upon the written
consent of the donor or the person authorized by law to
make the donation, or to authorized employees of the
department, or as permitted by law. The recipient's
name, address, and any other information that would
directly or indirectly identify the recipient shall not
be disclosed or released by the hematopoietic
progenitor cell bank to any person or entity, except
upon the written consent of the recipient, or except to
authorized employees of the department, or as permitted
by law.
(b) Records to be kept by the hematopoietic progenitor
cell procurement service shall include, but not be
limited to, the following information:
(1) donor's full name, address, age, sex, and
identification code, as well as documentation of donor
or donor's mother informed consent;
(2) date and volume of hematopoietic progenitor cells
collected;
(3) any adverse reaction of the donor and its outcome;
(4) medical history and results of all required
clinical laboratory tests and of the physical
examination performed;
(5) disposition of hematopoietic progenitor cells;
(6) documentation of sterility testing and viability
and recovery checks, if performed; and
(7) medical director's authorization for the
collection.
(c) Records to be kept by the hematopoietic progenitor
cell processing facility shall include, but not be
limited to, the following information:
(1) donor's identification code, date and amount of
cells collected;
(2) results of all clinical laboratory tests performed;
(3) methods used for processing, preserving, storage
and transport of the hematopoietic progenitor cells,
including manufacturer's name and lot numbers of
all reagents used in processing or preserving the
cells;
(4) temperature records of the storage chamber;
(5) records of visual inspection of the hematopoietic
progenitor cell specimens at the time of freezing and
thawing;
(6) specimen location in the storage chamber;
(7) methods used for hematopoietic progenitor cell
preservation, storage and transport; and
(8) disposition of the cells.
(d) Whenever hematopoietic progenitor cells are
released for transplantation, the following records
shall be maintained by the hematopoietic progenitor
cell transplantation facility:
(1) name of the hematopoietic progenitor cell bank
providing the cells, description of the specimen, and
condition of the cells and shipping container upon
receipt, including any loss noted of liquid nitrogen,
dry ice or other coolant;
(2) if applicable, any extenuating circumstances that
warrant acceptance of hematopoietic progenitor cells
from donors who test positive;
(3) medical history and results of all tests, and of
the physical examination performed on the donor, if
applicable;
(4) disposition of the hematopoietic progenitor cells,
including date and time released, and name of
recipient;
(5) outcome of the transplantation procedure,
including, but not limited to, any adverse outcome or
infectious disease in the recipient; and
(6) if applicable, records documenting storage and
temperature monitoring of hematopoietic progenitor
cells, in accordance with the requirements in section
58-5.7 of this Subpart.
58-5.9 Quality assurance and safety requirements.
(a) Quality assurance.
(1) The hematopoietic progenitor cell procurement
service and hematopoietic progenitor cell processing
facility shall keep records which indicate that a
quality assurance program is maintained in the
following areas:
(i) preventive maintenance, periodic inspections and
testing for proper operation of equipment;
(ii) monitoring of all temperature-controlled spaces
and equipment to ensure proper performance;
(iii) validation of microprocessor-controlled equipment
and associated software, including test plan protocols,
results of parallel testing and supervisory review; and
(iv) validation of hematopoietic progenitor cell
processing and testing methodologies.
(2) Hematopoietic progenitor cell processing,
laboratory and storage facilities shall be maintained
in a clean and orderly manner, and shall be of suitable
size, construction, and location to assure product and
personnel safety.
(3) All reagents and solutions shall be in-date, stored
properly, and labeled to indicate identity and, as
appropriate, titer, strength or concentration,
recommended storage requirements, preparation and/or
expiration date, and other pertinent information. All
such materials shall be removed from use on the
expiration date. Materials of substandard reactivity
and deteriorated materials shall be discarded
regardless of expiration date.
(4) All specimens accompanying the collected
hematopoietic progenitor cells shall be sufficiently
stable to provide accurate and precise test results
suitable for clinical interpretation. The hematopoietic
progenitor cell procurement service shall ensure that
specimens are collected, preserved and transported to
the laboratory in such a manner as to meet this
requirement. Specimens for analysis shall be identified
fully and accessioned in a log book. The accessioning
system shall be designed to allow tracing of the
hematopoietic progenitor cells to a specific donor, and
to identify the date and, if applicable, the time of
retrieval.
(5) Current standard operating procedure manuals
specific to the facility shall be available at all
times in the immediate work area of personnel engaged
in retrieval, processing, testing, storage,
distribution, or other hematopoietic progenitor cell
procurement activity. There shall be a written protocol
for all procedures performed. Manuals shall contain a
protocol for development, maintenance, and periodic
review of standard operating procedures by facility
personnel and management staff. Procedure manuals shall
have the following features:
(i) a standardized format for procedures;
(ii) a system of numbering and/or titling individual
procedures;
(iii) a clearly written description of purpose for each
procedure;
(iv) a reference section listing appropriate scientific
literature and industry and/or corporate standards
espoused by the hematopoietic progenitor cell
procurement service and/or processing facility;
(v) clearly defined areas of employee or technical
staff responsibility by position/title;
(vi) documented approval of procedures and procedural
modifications, including annual review by the director
of the hematopoietic progenitor cell procurement
service and/or processing facility, or authorized
supervisor;
(vii) instructions for the completion of reports and
forms, including examples;
(viii) effective date and date of review for each
procedure; and
(ix) a system for archiving earlier versions of
procedures and forms.
(6) The policies and procedures specified in the
procedure manual shall be followed at all times. If
deviations or deficiencies are identified, appropriate
corrective action shall be taken and documented.
(7) The director of the hematopoietic progenitor cell
procurement service and/or processing facility shall
establish and maintain a planned and periodic internal
review program for monitoring and evaluating the
quality and appropriateness of the hematopoietic
progenitor cell banking services. Included in the
program shall be systems for evaluating errors, and
designing, implementing and documenting corrective
action for any deficiencies identified. Quality
assurance deficiencies shall be documented, and
evidence shall be available that any operational or
procedural problems are reported to supervisory
personnel in a timely manner, and that corrective
action is implemented, documented and subsequently
followed-up.
(8) The director of the hematopoietic progenitor cell
procurement service and/or hematopoietic progenitor
cell processing facility shall be responsible for
developing policies, procedures and/or standards for
the qualifications, training, certification and
continuing education of technical staff. Documentation
of compliance with this requirement and with the
policies developed shall be maintained.
(b) Safety.
(1) The hematopoietic progenitor cell procurement
service and/or processing facility shall implement
written safety and infection control policies and
procedures to ensure protection from unnecessary
physical, chemical and biological hazards, as follows:
(i) Decontamination and disposal techniques for
regulated medical waste shall be utilized. All
hazardous and regulated medical waste materials shall
be handled, stored and discarded pursuant to Part 70 of
this Title.
(ii) If sterilization equipment is used, the pressure,
temperature and duration of each cycle shall be
recorded, and such records maintained for one year. For
each run, these parameters shall be within the
manufacturer's recommended operating standards. If
any one or more of these parameters fall(s) outside the
manufacturer's standards, all material shall be
resterilized. Chemical, biological and physical
detection systems should be used in conjunction with
these other measurements of performance.
(iii) Eating, drinking, smoking, or the application of
cosmetics or contact lenses shall not be permitted in
work areas. Refrigerators or freezers used for storing
specimens or reagents shall not be used for any other
purpose.
(iv) Gloves and laboratory coats, gowns or other
protective clothing shall be worn as necessary while
handling blood specimens or hematopoietic progenitor
cell tissue. Such protective clothing shall not be worn
outside the work area and shall be disposed of in an
appropriate receptacle.
(2) The hematopoietic progenitor cell procurement
service and/or processing facility shall have written
policies and procedures in the following areas:
(i) infection control;
(ii) biosafety;
(iii) chemical and radiological safety;
(iv) emergency response to worksite accidents; and
(v) medical waste disposal.
(3) The safe collection of peripheral blood
hematopoietic progenitor cells by apheresis shall be
the responsibility of the medical director of the
apheresis service. Collection shall be performed in
full compliance with section 58-2.15 of this Part.
(4) Hematopoietic progenitor cell transplantation
facilities shall report suspected cases of infectious
disease transmission in recipients to the hematopoietic
progenitor cell bank providing the tissue.
(5) The hematopoietic progenitor cell bank shall have a
written procedure for documenting any errors or
accidents in retrieval, testing, processing, storage or
disposition of hematopoietic progenitor cells that may
affect the safety of the cells, and for reporting such
errors or accidents to the medical advisory committee
of the bank. If the error or accident is detected after
issuance of the cells, the error or accident shall be
reported to the receiving facility immediately upon
detection by the distributing facility. All errors with
the potential for serious adverse effects on the
recipient shall also be reported to the
department's Wadsworth Center within seven (7)
calendar days of discovery.
58-5.10 Compliance with standards.
(a) Hematopoietic progenitor cell procurement services
and/or processing facilities shall allow admission to
representatives of the department for the purpose of
inspecting the premises and evaluating operating
procedures, equipment, and records, including financial
records and lists of physicians or facilities to whom
or to which hematopoietic progenitor cells are
released, to determine compliance with the standards in
this Subpart. If the Commissioner determines that a
significant likelihood exists that adequate safeguards
are not implemented, the department may require that
cells not be released pending a hearing. Such hearing
shall commence within fifteen (15) days of any
suspension pursuant to this section.
(b) Whenever requested, a hematopoietic progenitor cell
bank shall submit to the department reports containing
such information and data concerning the bank's
activities as may be required by this Subpart. Such
reports shall be signed by the director of the
hematopoietic progenitor cell bank.
58-5.11 Licensure.
No person shall own or operate a hematopoietic
progenitor cell procurement service, processing
facility or transplantation facility in New York State
unless licensed by the department under Subpart 52-2 of
this Title. All provisions of Subpart 52-2 of this
Title shall apply to a hematopoietic progenitor cell
procurement service, processing facility and/or
transplantation facility, except for the record keeping
requirements contained in section 52-2.9 of this Title.
58-5.12 Special circumstances.
(a) The department may exempt a hematopoietic
progenitor cell bank from a specific standard contained
in this Subpart, provided:
(1) the hematopoietic progenitor cell bank has
requested an exemption under limited circumstances
prior to the noncompliance with the standard; and
(2) the hematopoietic progenitor cell bank has
demonstrated to the department that application of the
standard to such bank under the limited circumstances
for which the exemption is sought:
(i) is inconsistent with the provision of the
particular service, as documented in properly conducted
current medical or scientific research, or current
scientific literature;
(ii) is incompatible with a requirement imposed by a
federal or other state's government unit which is
similar to the standard for which the exemption is
sought, and the department determines that the
requirement imposed by the federal or other state's
governmental unit adequately protects the public
health, safety and welfare, based upon commonly
accepted medical standards, properly conducted medical
or scientific research, or current scientific
literature; or
(iii) would prevent or impair the provision of services
necessitated by a medical emergency or special medical
condition. Hematopoietic progenitor cell banks seeking
an exemption pursuant to this subparagraph shall
describe the nature of the emergency or special medical
condition and the exemption requested, for review on a
case-by-case basis by the department. All such
emergencies or special medical conditions shall be
documented in the medical record, and any action taken
in response which is contrary to the requirements of
this Subpart shall be approved by the director of the
hematopoietic progenitor cell transplantation service.
(b) A copy of the department's approval for an
exemption shall be maintained by the hematopoietic
progenitor cell transplantation facility and the
hematopoietic progenitor cell bank releasing the cells.



