| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01P001 | (X3) Date Survey Completed 03/29/2018 |
| 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) |
| Z0085 | ADMINISTRATION AND GOVERNING BODY CFR(s): 486.324(a) While an OPO may have more than one board, the OPO must have an advisory board that has both the authority described in paragraph (b) of this section and the following membership: This STANDARD is not met as evidenced by: Based on staff interview and review of the Advisory Board Bylaws the Organ Procurement Organization (OPO) failed to verify qualifications of the Advisory Board members for 13 of 14 members. The findings include: Review of the OPO document entitled, "Advisory Board Policies and Bylaws," dated 6/2/14, revealed, "Members of the Advisory Board will provide a signed and dated copy of their curriculum vitae (CV) confirming their qualifications to serve in the so designated position for which they were appointed." Further review revealed there was no content concerning the process for initial and/or annual verification of Advisory Board (AB) member qualifications. During an interview on 3/27/18 at 10:47 A.M., the Director of Quality Management (DQM) acknowledged that the OPO did not have a policy or procedure for verifying the qualifications of the OPO members and that this was not addressed in the Advisory Committee Bylaws. She also stated that while the OPO did obtain a copy of the CV for each member, they did not take steps to verify the stated qualifications. |