| 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) |
| Z0162 | DATA RETENTION CFR(s): 486.330(c) Donor and transplant recipient records must be maintained in a human readable and reproducible paper or electronic format for 7 years. This STANDARD is not met as evidenced by: Based on the facility's "Record Retention" policy review and staff interview, the Organ Procurement Organization (OPO) failed to define the time frame for record retention of OPO donor records. The findings include: The facility's "Record Retention" policy, dated 6/15/13, documented "PURPOSE: To establish guidelines for the retention period of records, to identify specific records to be retained and the language of the documentation . . ." Although this was defined as the purpose, the policy review revealed there was no time frame defined for record retention of the OPO's donor records. During interview with the OPO's Senior Manager of Professional Education on 4/17/14 at approximately 3:03 p.m., she confirmed their "Record Retention" policy did not include a time frame. |