| 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) |
| Z0084 | ADMINISTRATION AND GOVERNING BODY CFR(s): 486.324 Administration and governing body. This CONDITION is not met as evidenced by: Based on record review and staff interview, the OPO's Governing Body/Board of Directors (BOD) did not ensure effective administration of the organization took place in the following areas: (1) Clarity of the OPO's role in the training of Hospital Designated Requestors, (2) Ensuring the Advisory Board had established and documented Bylaws and (4) that Quality Improvement initiatives that affected the OPO were either established, reviewed or effective. The OPO's cumulative lack of compliance at Standards Z085, Z092 & Z095 rose to the Condition Level of non-compliance.. The findings include: Cross Refer to Z085: Based on interview and record review, the Governing Body/ Board of Directors (BOD) failed to ensure the Advisory Board had established Bylaws. Cross Refer to Z092: Based on record review and interview, the BOD did not ensure there were systematic efforts in place to educate the hospital designated requestors (HDRs) in order to increase the potential of the OPO to acquire useable organs and tissue from potential donors and per the Hospital Agreements. Cross Refer to Z095: Based on interview, the BOD did not define the duties of the Executive Director to address all aspects of Quality Improvement in the OPO. |