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)
Z0168 POTENTIAL DONOR PROTOCOL MANAGEMENT
CFR(s): 486.344(a)(1)

The medical director is responsible for ensuring that potential donor evaluation and management protocols are implemented correctly and appropriately to ensure that potential donors are thoroughly assessed for medical suitability for organ donation and clinically managed to optimize organ viability and function.


This STANDARD is not met as evidenced by:
Based on interview and record review, the Organ Procurement Organization (OPO) failed to have a written procedure for and provide evidence that the Medical Director reviewed Donor Records for assessment for medical suitability for organ donation and for clincial management to optimize organ viability and function. The findings include: Interview conducted during Donor Record reviews on 4/17/14 at 9:20 a.m., with the Certified Procurement Transplant Coordinator (CPTC), revealed the Medical Director did not review the Donor Records. The CPTC stated, "The Medical Director does not review the donor records."