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)
Z0120 QUALIFICATIONS
CFR(s): 486.326(a)(3)

The OPO must have credentialing records for physicians and other practitioners who routinely recover organs in hospitals under contract or arrangement with the OPO and ensure that all physicians and other practitioners who recover organs in hospitals with which the OPO has agreements are qualified and trained.


This STANDARD is not met as evidenced by:
Based on OPO personnel interview and donor record review on July 10, 2018, the OPO failed to ensure that it had credentialing records to ensure that all physicians and other practitioners who recovered organs in hospitals with which the OPO had agreements were qualified and trained. Findings included: a. During an interview on July 10, 2018, OPO personnel stated that the OPO used the ACIN (AOPO Credentials Information Network) to establish the credentials of physicians who originated from outside the OPO's designated service area (DSA) that recovered organs on the OPO's behalf. The ACIN, an online database maintained by the AOPO (Association of Organ Procurement Organizations), enables OPO's to verify the credentials and/or qualifications and training of physicians prior to organ recovery. However, although ACIN information includes which organ(s) any given physician is credentialed to recover and the physician's license number, the ACIN does not include the expiration date of the physician's license to ensure that the license is current at the time of organ recovery. b. For one (ADAZ398) of twelve randomly selected donor records from January 2016 to June 2018, the OPO used the ACIN to establish the credentials of physicians who originated outside the OPO's DSA, and did not verify whether these physicians had valid licenses at the time of organ recovery. For ADAZ398, OPO donor records indicated that on January 29, 2016 the OPO recovered a liver using a physician from outside the OPO's DSA.