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 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)
Z0090 ADMINISTRATION AND GOVERNING BODY
CFR(s): 486.324(a)(5)

[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:] A transplant surgeon representing each transplant hospital in the service area with which the OPO has arrangements to coordinate its activities. The transplant surgeon must have practicing privileges and perform transplants in the transplant hospital represented.


This STANDARD is not met as evidenced by:
Based on staff interview, document review and review of the Advisory Board Membership, the Organ Procurement Organization (OPO) failed to include transplant surgeons from three of three (3 of 3) transplant hospitals (Transplant Hospitals A, B and C) as members of the Advisory Board. The findings include: Review of the OPO document entitled, "Advisory Board Policies and Bylaws," dated 6/2/14, revealed the Advisory Board was to include the following members: "A transplant surgeon representing each transplant hospital in the DSA (Designated Service Area) with which the OPO has arrangements to coordinate it's activities. The transplant surgeon must have practicing privileges and perform transplants in the hospital represented." A review of the OPO Advisory Board Membership List, dated 2014 - 2018, revealed all 3 transplant hospitals had members on the Advisory Board but none of these members were identified as being a transplant surgeon. During an interview on 3/29/18 at 12:00 P.M., the Director of Quality Management (DQM) verified that the transplant hospital representatives on the Advisory Board were not transplant surgeons. She also said that the Advisory Board did not have any transplant surgeons on the Board other that the OPO's own Medical Director.