| 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) |
| Z0121 | STAFFING CFR(s): 486.326(b)(1) The OPO must provide sufficient coverage, either by its own staff or under contract or arrangement, to assure both that hospital referral calls are screened for donor potential and that potential donors are evaluated for medical suitability for organ and/or tissue donation in a timely manner. This STANDARD is not met as evidenced by: Based on donor record review, staff interview and review of the "Responding to a Potential Donor" policy, the Organ Procurement Organization (OPO) failed to arrive promptly onsite for 7 of 10 donors (Donor #s 6, 10, 4, 7, 8, 5 and 3) and failed to define the timeframe for initial response onsite at the donor hospital within their policy. The findings include: Review of Donor #s 6, 10, 4, 7, 8, 5 and 3 records revealed the following: 1. Donor #6 was referred on 6/25/15 (no time indicated). The onsite arrival of OPO staff was documented as 6/29/15 at 11:40 A.M. The response time was approximately 4 days. 2. Donor #10 was referred on 12/23/17 at 12:50 A.M. The onsite arrival of OPO staff was documented as 12/24/17 at 1:15 P.M. The response time was 1 day, 12 hours and 25 minutes 3. Donor #4 was referred on 3/8/15 at 2:24 P.M. The onsite arrival of OPO staff was documented as 3/9/15 at 1:30 P.M. The response time was 23 hours and 6 minutes. 4. Donor #7 was referred on 2/22/17 at 12:14 P.M. The onsite arrival of OPO staff was documented as 2/23/17 at 11:10 A.M. The response time was 22 hours and 46 minutes. 5. Donor #8 was referred on 1/31/18 at 5:58 P.M. The onsite arrival of OPO staff was documented as 2/1/18 at 9:20 A.M. The reponse time was 15 hours and 32 minutes. 6. Donor #5 was referred on 5/16/16 at 5:55 P.M. The onsite arrival of OPO staff was documented as 5/17/16 at 09:00 A.M. The response time was 15 hours and 5 minutes. 7. Donor #3 was referred on 7/13/16 at 5:08 A.M. The onsite arrival of OPO staff was documented as 7/13/16 at 10:00 A.M. The response time was 4 hours and 52 minutes. Review of the OPO's policy entitled "Responding to a Potential Donor," dated 12/5/14, documented, ". . . Timely response to donor hospital referrals is vital to a successful organ procurement effort, and to providing good customer service to the hospital. . ." During an interview on 3/28/18 at 4:40 P.M, Family Support Coordinator #1 (FSC #1) explained that once a referral came in, the FSC called the hospital Nurse to gather information and then discussed the case with the OPO Administrator On-Call (AOC). At that time, the AOC made the determination of when the FSC went onsite (e.g. immediately or delayed pending further developments). FSC #1 also confirmed that there was no specified timeframe within which the initial onsite hospital arrival and onsite evaluation needed to occur and that it was determined on a case by case basis. During an interview on 3/29/18 at 10:00 A.M., the Clinical Director stated after a Donor referral was made, the OPO staff onsite arrival time was not tracked or monitored because there was no policy in place. |