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)
Z0092 ADMINISTRATION AND GOVERNING BODY
CFR(s): 486.324(b)

The OPO board described in paragraph (a) of this section has the authority to recommend policies for the following: (1) Procurement of Organs. (2) Effective agreements to identify potential organ donors with a substantial majority of hospitals in its service area that have facilities for organ donation. (3) Systematic efforts, including professional education, to acquire all useable organs from potential donors. (4) Arrangements for the acquisition and preservation of donated organs and provision of quality standards for the acquisition of organs that are consistent with the standards adopted by the OPTN, including arranging for testing with respect to preventing the acquisition of organs that are infected with the etiologic agent for acquired immunodeficiency syndrome (AIDS). (5) Appropriate tissue typing of organs. (6) A system for allocation of organs among transplant patients that is consistent with the rules and requirements of the OPTN, as defined in ยง486.320 of this part. (7) Transportation of organs to transplant hospitals. (8) Coordination of activities with transplant hospitals in the OPO's service area. (9) Participation in the OPTN. (10) Arrangements to cooperate with tissue banks for the retrieval, processing, preservation, storage, and distribution of tissues as may be appropriate to assure that all useable tissues are obtained from potential donors. (11) Annual evaluation of the effectiveness of the OPO in acquiring organs. (12) Assistance to hospitals in establishing and implementing protocols for making routine inquiries about organ donations by potential donors.


This STANDARD is not met as evidenced by:
Based on record review and interview, the Governing Body/Board of Directors (BOD) did not ensure there were systematic efforts in place to educate the hospital designated requestors (HDRs) to increase the potential of the OPO to acquire useable organs and tissue from potential donors. The findings include: Cross Refer to Z057 and Z058. The BOD did not ensure the education of HDRs took place according to the Organ Procurement Organization Agreement (Version 8/1/12) for 125 of 125 hospitals in the designated service area. According to interview of the Certified Procurement Transplant Coordinator (CPTC) on 4/18/14 at approximately 9:30 a.m., and record review of the Governing Body Bylaws, HDR Training needs were not addressed. 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. The BOD did not ensure the HDRs were trained according to the Hospital Agreements, or that there was a system in place to identify those HDRs who were in need of training.