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 04P001 (X3) Date Survey Completed 05/06/2010
Name of Provider or Supplier Arkansas Organ Recovery Agency Street Address, City, State 1701 Aldersgate Road, Suite 4, Little Rock, AR
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)
Z0261 QUALIFICATIONS
CFR(s): 486.36(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 record review the OPO (Organ Procurement Organization) did not ensure the credentials were verified for 4 physicians who recovered organs in 4 of 8 donor records reviewed. A review of the OPO policy entitled "Operating Room Procedures For Organ and Recovery" stated: "The Arkansas Regional Organ Recovery Agency will ensure that any visiting recovery personnel is credentialed to perform the recovery of the specific organ. This will be accomplished by referencing the AOPO online AOPO Cedentialls Information Network (ACIN) database." 1. A review of donor record #5 revealed Dr. A recovered the heart. A review of the credential files revealed the OPO did not have credentials for Dr.A. 2. A review of donor record #4 revealed Dr. B. recovered Pancreas/Intestines/Liver. A review of the credential files revealed the OPO did not have confirmation of verification of credentials for the physician. 3. A review of donor record #3 revealed Dr. C. recovered the heart. A review of the credential files revealed the OPO did not have confirmation of verification of credentials for the physician. 4. A review of donor record #7 revealed Dr. D recovered the liver. A review of the credential files revealed the OPO did not have confirmation of verification of credentials for the physician.