| 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) |
| Z0095 | ADMINISTRATION AND GOVERNING BODY CFR(s): 486.324(e) A governing body must have full legal authority and responsibility for the management and provision of all OPO services and must develop and oversee implementation of policies and procedures considered necessary for the effective administration of the OPO, including fiscal operations, the OPO's quality assessment and performance improvement (QAPI) program, and services furnished under contract or arrangement, including agreements for these services. The governing body must appoint an individual to be responsible for the day-to-day operation of the OPO. This STANDARD is not met as evidenced by: Based on interview, the Governing Body/Board of Directors (BOD) did not define the duties of the Executive Director to address all aspects of Quality Improvement in the OPO. The findings include: Cross Refer to Z200. Document review revealed there was no QAPI plan that included objective measures which evaluated and demonstrated improved performance of the OPO activities since the last recertification in 2010. During interview with the OPO's Executive Director, Chief Operating Officer, Senior Manager of Professional Education and the Manager of Professional Development & [and] Process Improvement on 4/17/14 at approximately 5:00 p.m., they confirmed there currently was no QAPI Director, no QAPI Plan since 2010, and the OPO was in the process of redeveloping their QAPI program. |