| 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) |
| Z0148 | REPORTING OF DATA CFR(s): 486.328(c) Data to be used for OPO re-certification purposes must be reported to the OPTN and must include data for all deaths in all hospitals and critical access hospitals in the OPO's donation service area, unless a hospital or critical access hospital has been granted a waiver to work with a different OPO. This STANDARD is not met as evidenced by: Based on document review and staff interview, the Organ Procurement Organization (OPO) failed to submit data to the Organ Procurement and Transplantation Network (OPTN) for one (1) of eight (8) hospitals reviewed (Hospital #8) since the last OPO recertification. The findings include: Document review revealed the OPO did not submit data on deaths which occurred at Hospital #8 to OPTN between 2011 - present. During interview with the OPO's Senior Manager of Professional Education and the OPO's Manager of Professional Development & [and] Process Improvement on 4/17/14 at approximately 4:50 p.m., they confirmed the OPO did not submit data to OPTN for this hospital due to problems encountered collecting data from Hospital #8. When the surveyor inquired if the OPO developed a process improvement plan to address this problem, both the Senior Manager of Professional Education and the Manager of Professional Development & [and] Process Improvement said "No." |