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 05P001 (X3) Date Survey Completed 04/02/2014
Name of Provider or Supplier Lifesharing Street Address, City, State 7436 Mission Valley Road, San Diego, CA
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)
Z0096 ADMINISTRATION AND GOVERNING BODY
CFR(s): 486.324(f)

The OPO must have procedures to address potential conflicts of interest for the governing body described in paragraph (d) of this section.


This STANDARD is not met as evidenced by:
Based on interview and review of policy and procedures, the OPO's governing body did not consistently include in the written policy the frequency in evaluating and disclosure of any potential conflict of interest with the activities of OPO. Findings include: Review of the Governing Body policy Document Number: ORAS-008 with "Routing Approval Process-2/4/14 revealed the University of California (UC) Regents is the Governing Body of the OPO. The document also indicated that The UC San Diego Health System Governance Advisory Committee (GAC) will provide oversight for annual review of policies. The Conflict of Interest policy with effective date of 1/31/14 established guidelines to avoid any potential conflict of interest between an OPO employee or agent and OPO or the UCSD. The policy further stated that the OPO will comply with all UCSD policies and procedures regarding conflict of interest. The employee training policy indicated that employees will annually review and acknowledge the OPO's conflict of interest policy. Interview with OPO staff on 4/2/14 revealed that GAC members acknowledge and sign the "Code of Business Conduct" bi-annually as required by training. The OPO staff also stated that the form is signed upon employment and as part of mandatory training as UCSD employee. Review of the Code of Business Conduct form revealed a section related to "Avoidance of Conflicts of Interest or Commitment." Random review of five acknowledgement forms revealed that the conflict of interest forms were signed bi-annually and not annually as required. During an interview of the OPO staff on 4/2/14, a current list of members of the GAC and the Advisory Board was provided. The staff indicated that the Advisory Board members sign a form "Disclosure of Outside Interests and Activities and Statement Regarding Such Interests and Activities." The form revealed that all members of the OPO's Advisory Board and GAC (Governing Body as delegated by the Regents) shall be completed and submitted to the OPO's Executive Director for review annually. Review of 11 of 20 disclosure forms for the current members of the Advisory Board revealed the forms were not signed annually. In addition, these disclosure forms were not signed by members of the GAC. When asked of the missing 2011 disclosure forms, the OPO staff stated that an executive assistant who was in-charge of the disclosure forms went on leave and never came back, thus the 2011 disclosure forms were never recovered.