| 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) |
| Z0094 | ADMINISTRATION AND GOVERNING BODY CFR(s): 486.324(d) The OPO must have bylaws for each of its board(s) that address potential conflicts of interest, length of terms, and criteria for selecting and removing members. This STANDARD is not met as evidenced by: Based on document review and staff interview, the Organ Procurement Organization (OPO) failed to have bylaws for it's Governing Body (Operating Committee) for four of four (4 of 4) years (2014 - 2018). The findings include: During an interview on 3/26/18 at 9:30 A.M., the Director Quality Management (DQM) stated that the OPO's Operating Committee was the Governing Body. She also revealed that this OPO was a University Based OPO and the University gave the OC the role of Governing Body via a Charter document dated 6/5/14. Review of the Charter document revealed the Executive Vice President of the University's Health Services Foundation appointed the OC with the responsibility for the management and provision of all OPO services and required an annual report the the University's Health Services Foundation Board every year. Further review of the Charter revealed there was no reference made to OC Bylaws, potential conflicts of interest for the OPO OC/Governing Body members or criteria for seeking or removing OC members. The OC members were identified in the Charter and included three (3) University Health Services Foundation Board members and the OPO Medical Director. The Charter also listed the OPO Executive Director as an ex-officio member, however the OPO Executive Director's participatory rights were not defined. Lastly the Charter revealed that appointments to the OC were to be for a period of three (3) years. Review of the Meeting sign-in sheets from 2014 - 2018 for the OC as well as the OC membership list revealed that the Medical Director did not participate as a member of the OC as indicated in the Charter document. In addition, the review indicated that appointments to the OC had not been reviewed since 6/5/14. During an interview on 3/29/18 at 12:00 P.M., the DQM confirmed that the OPO's Governing Body did not have Bylaws or OPO specific policies regarding conflicts of interest and criteria for seeking and removing OC members. |