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)
Z0118 QUALIFICATIONS
CFR(s): 486.326(a)

(1) The OPO must ensure that all individuals who provide services and/or supervise services, including services furnished under contract or arrangement, are qualified to provide or supervise the services.


This STANDARD is not met as evidenced by:
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). The findings include: Employee #1 worked as the Assistant Tissue Manager for the OPO. During record review of Employee # 1's file, the Assistant Tissue Manager (ATM) job description documented, " . . . Experience as an Operating Room (OR) Scrub Nurse or OR Technician . . ." as a requirement for the position. According to the job description, the ATM is responsible for tissue procurement for training of tissue recovery staff in assigned regions. Review of Employee #1's file documented no experience as an OR Scrub Nurse or an OR Technician. Employee #2 worked in one of the OPO's Procurement Transplant Coordinator II positions. During record review of the employee's file, the Procurement Transplant Coordinator II job description documented, ". . . Completion of BCLS and/or ACLS [Basic Cardiac Life Support and/or Advanced Cardiac Life Support] . . ." as a requirement for the position. BCLS is a certification for providing basic medical interventions and ACLS is certification in the clinical interventions for the urgent treatment of cardiac arrest, stroke and other life threatening medical emergencies, as well as knowledge and skills to deploy those interventions. There was no evidence of current BCLS and/or ACLS documented in Employee #2's file. During interview with the OPO's Manager of Professional Development & [and] Process Improvement on 4/17/14 at approximately 4:20 p.m., she confirmed Employee #1 did not have experience as an OR Scrub Nurse or an OR Technician as well as Employee #2 did not have a current BCLS and/or ACLS in the file.