| 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) |
| Z0340 | DEATH RECORD REVIEWS CFR(s): 486.348(b) (b) Standard: Death record reviews. As part of its ongoing QAPI efforts, an OPO must conduct at least monthly death record reviews in every Medicare and Medicaid participating hospital in its service area that has a Level I or Level II trauma center or 150 or more beds, a ventilator, and an intensive care unit (unless the hospital has a waiver to work with another OPO), with the exception of psychiatric and rehabilitation hospitals. When missed opportunities for donation are identified, the OPO must implement actions to improve performance. This STANDARD is not met as evidenced by: Based on interview and record review the Organ Procurement Organization (OPO) failed to ensure its death record review policy specified the components that should be included in the review and the timeframes for summarization of reviews to the hospitals and to the OPO Quality Assessment and Performance Improvement (QAPI) committee. The OPO policy entitled: "Hospital Development Programs Potential Donor Assessment Compliance Policy" did not include information on how recommendations are reported, acted upon and followed up. During interview on 5/5/10 at 2:00 PM the Director of Clinical Services verified the OPO did not have written policies for the timeframes for summarization of the medical record reviews and submission to the QAPI committee. |