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)
Z0117 HUMAN RESOURCES
CFR(s): 486.326

All OPOs must have a sufficient number of qualified staff, including a director, a medical director, organ procurement coordinators, and hospital development staff to obtain all usable organs from potential donors, and to ensure that required services are provided to families of potential donors, hospitals, tissue banks, and individuals and facilities that use organs for research.


This CONDITION is not met as evidenced by:
Based on interview and record review, the OPO failed to ensure all employees met the criteria established in their job descriptions (Employee #'s 1 & 2), (2) that Conflict of Interests Policies were established for the Executive Director, the Medical Director, Senior Management and the Procurement Coordinators and (3) that there was sufficient staff to request or document whether or not requesting of organs/tissue of potential donor families/qualified significant others, was done in a timely manner. The cumulative lack of compliance at the Standard levels of Z118, Z119 and Z121rose to the Condition Level of non-compliance.. The findings include: 1. Cross Refer to Z118: Based on record review and staff interview, the Organ Procurement Organization (OPO) failed to maintain current evidence of qualifications as required by employee job descriptions in two (2) of eight (8) employee files reviewed (Employee #'s 1 and 2). 2. Cross Refer to Z119: Based on interview, the Organ Procurement Organization did not have written policies and procedures for the identification, investigation and resolution of potential conflicts of interest (financial or personal) for the OPO director, medical director, senior management and procurement coordinators. 3. Cross Refer to Z121: Based on record review, the facility failed to ensure there was sufficient staff to request or document whether or not requesting of organs/tissue of potential donor families/qualified significant others, was done in a timely manner.