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)
Z0180 COLLABORATION WITH TRANSPLANT PROGRAMS
CFR(s): 486.344(d)(1)

The OPO must establish protocols in collaboration with transplant programs that define the roles and responsibilities of the OPO and the transplant program for all activities associated with the evaluation and management of potential donors, organ recovery, and organ placement, including donation after cardiac death, if the OPO has implemented a protocol for donation after cardiac death.


This STANDARD is not met as evidenced by:
Based on document review and staff interview, the Organ Procurement Organization (OPO) failed to establish written agreements or Memorandum of Understanding (MOU) with three (3) of the three (3) certified transplant hospitals within the OPO's designated service area (Hospital #'s 1, 2 and 8) that was separate from its agreement with the hospital portion of the transplant program. The findings include: Document review revealed there was no written agreement or MOU between the OPO and the certified Transplant Hospital #'s 1, 2 and 8 located in the OPO's designated service area which defined the role and responsibilities of the transplant program as well as defined donation after cardiac death. During interview with the OPO's Certified Procurement Transplant Coordinator on 4/17/14 at approximately 4:10 p.m., he confirmed there was no agreement or MOU with the OPO's three transplant hospitals that defined the transplant program's role and responsibilities that was separate from the OPO's contract with the hospital.