Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 01P001 (X3) Date Survey Completed 04/18/2014
Name of Provider or Supplier Legacy Of Hope Street Address, City, State 516 20th Street South, Birmingham, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
Z0057 HOSPITAL AGREEMENTS
CFR(s): 486.322(a)

An OPO must have a written agreement with 95 percent of the Medicare and Medicaid participating hospitals and critical access hospitals in its service area that have both a ventilator and an operating room and have not been granted a waiver by CMS to work with another OPO. The agreement must describe the responsibilities of both the OPO and hospital or critical access hospital in regard to donation after cardiac death (if the OPO has a protocol for donation after cardiac death) and the requirements for hospitals at § 482.45 or §485.643. The agreement must specify the meaning of the terms "timely referral" and "imminent death."


This STANDARD is not met as evidenced by:
Based on interview and record review, the OPO Governing Body failed to ensure hospital designated requestor (HDR) training was provided according to the criteria established in 125 of 125 Hospital Agreements reviewed. The findings include: Review of the OPO's 125 Hospital Agreements (Organ Procurement Organization Agreements) was conducted on 4/14-15/14. The agreements stated the OPO, upon request of the Donor Hospital, would provide HDR training for Donor Hospital staff. The agreements further stated the Donor Hospital would ensure, (in collaboration with the OPO), the family of each potential donor was informed of their options to donate or decline to donate organs, or tissue, by a HDR or by a trained AOC employee or agent. During review of the Donor Records on 4/16/14 at 10:30 a.m. and 1:30 p.m., the Certified Procurement Transplant Coordinator (CPTC) was interviewed regarding prompt response to the hospital regarding referral time for potential donation of an organ and the date and time that the OPO designated requestor (OPO DR) would arrive on site. The CPTC stated all OPO DRs were designated requestors and were trained regarding approaching family members; however, sometimes the HDRs have to make the request if the OPO DRs were detained. Further interview of the CPTC on 4/18/14 at approximately 9:30 a.m., and review of HDR Training Records at that time, revealed the OPO had not maintained records of training for the HDRs to identify those who had discontinued employment with the hospitals since 2010, could not identify those who were in need of current training, or included data to indicate the training had occurred per the agreements.