| 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) |
| Z0147 | REPORTING OF DATA CFR(s): 486.328(b) An OPO must provide hospital-specific organ donation data annually to the transplant hospitals with which it has agreements. This STANDARD is not met as evidenced by: Based on document review and staff interview, the Organ Procurement Organization (OPO) failed to include all of the required elements in their Hospital-Specific Organ Donation annual data reports for three (3) of three (3) transplant hospitals (Hospital #'s 1, 2 and 8). The findings include: Document review revealed there was no documentation of the number of organs recovered by type of organ and the number of organs transplanted by type of organ in the Hospital-Specific Organ Donation annual data reports provided to the OPO's transplant hospitals. During interview with the OPO's Senior Manager of Professional Education on 4/17/14 at approximately 3:03 p.m., she confirmed these elements were not present in the annual data reports provided to the transplant hospitals. |