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)
Z0121 STAFFING
CFR(s): 486.326(b)(1)

The OPO must provide sufficient coverage, either by its own staff or under contract or arrangement, to assure both that hospital referral calls are screened for donor potential and that potential donors are evaluated for medical suitability for organ and/or tissue donation in a timely manner.


This STANDARD is not met as evidenced by:
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. The findings include: Based on interview of the Senior Manager of Professional Education (SMPE) on 4/18/14 at 1:45 p.m., and review of the OPO's response time documents, the information provided to demonstrate compliance with sufficient staff coverage to ensure timely response was not defined or consistently evaluated by the OPOs . The Call /Response Time Log was requested on 4/17/14 (Thursday), at 2:00 p.m. On 4/18/14 (Friday), at 1:30 p.m., prior to the Exit Conference, some of the staff response data was provided on 4/18/14 at 1:45 p.m.; however, it was incomplete. The data was not reviewed or evaluated by the OPO staff to ensure there was sufficient staff to address approaching families/qualified significant others of potential donors in a timely manner. During the interview of the SMPE, she stated the OPO staff realized they would have to address the response times as related to staffing needs.