| 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) |
| Z0200 | COMPONENTS OF A QAPI PROGRAM CFR(s): 486.348(a) The OPO's QAPI program must include objective measures to evaluate and demonstrate improved performance with regard to OPO activities, such as hospital development, designated requestor training, donor management, timeliness of on-site response to hospital referrals, consent practices, organ recovery and placement, and organ packaging and transport. The OPO must take actions that result in performance improvements and track performance to ensure that improvements are sustained. This STANDARD is not met as evidenced by: Based on document review and staff interview, the Organ Procurement Organization (OPO) failed to develop a Quality Assurance Performance Improvement (QAPI) Plan since their last Recertification Survey in 2010. The findings include: Document review revealed there was no QAPI Plan that included objective measures which evaluated and demonstrated improved performance of the OPO activities since the last recertification in 2010. During interview with the OPO's Executive Director, Chief Operating Officer, Senior Manager of Professional Education and the Manager of Professional Development & [and] Process Improvement on 4/17/14 at approximately 5:00 p.m., they confirmed there currently was no QAPI Director, no QAPI plan since 2010 and the OPO was in the process of redeveloping their QAPI program. |