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)
Z0085 ADMINISTRATION AND GOVERNING BODY
CFR(s): 486.324(a)

While an OPO may have more than one board, the OPO must have an advisory board that has both the authority described in paragraph (b) of this section and the following membership:


This STANDARD is not met as evidenced by:
Based on interview and record review, the Organ Procurement Organization (OPO) failed to ensure there were written bylaws for the Advisory Board (AB). The findings include: Interview conducted with the Certified Procurement Transplant Coordinator (CPTC) on 4/18/14 at 9:28 a.m. and record review of the AB activities revealed there were no Advisory Board Bylaws.