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 03P001 (X3) Date Survey Completed 07/11/2018
Name of Provider or Supplier Donor Network Of Arizona Street Address, City, State 201 West Coolidge, Phoenix, AZ
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)
Z0007 OUTCOME MEASURES
CFR(s): 486.318(a)(3)(iii)

[At least 2 out of the 3 following yield measures are no more than 1 standard deviation below the national mean, averaged over the 4 years of the re-certification cycle:] The number of organs used for research per donor, including pancreata used for islet cell research.


This STANDARD is not met as evidenced by:
Based on data received from the OPO as of February 28, 2018, as confirmed by OPO personnel on July 10, 2018, the OPO failed to achieve a measure of less than 1 standard deviation below the national mean, averaged over the four years of the recertification cycle, for the number of organs used for research per donor, including pancreata used for islet cell research. Findings included: a. The national mean for the number organs for research per donor, averaged over the four years of the recertification cycle, was 0.51, resulting in the cutoff of 1 standard deviation below the national mean being calculated as 0.25. b. Based on data submitted by the OPO as of February 28, 2018, the OPO's standard deviation for the number of organs used for research per donor was calculated as 0.26, greater than the cutoff of 0.25.