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)
Z0125 MEDICAL DIRECTOR
CFR(s): 483.326(d)

The OPO's medical director is a physician licensed in at least one of the States or territories within the OPO ' s service area or as required by State or territory law or by the jurisdiction in which the OPO is located. The medical director is responsible for implementation of the OPO's protocols for donor evaluation and management and organ recovery and placement. The medical director is responsible for oversight of the clinical management of potential donors, including providing assistance in managing a donor case when the surgeon on call is unavailable.


This STANDARD is not met as evidenced by:
Based on record review and interview the OPO's medical director did not conduct an annual review of each surgeon's credentialing records. Findings include: On 4/2/14 at 1:15 p.m. during an interview with the OPO's medical director, he stated that he is currently working on improving in his responsibility for assessing the credentials of the procurement surgeons. Review of the responsibilities unique to the OPO's Medical Director Document Number ORAS-007 effective 9/14/12 revealed "Responsible for the on-going assessment of the surgical and technical credentials of procurement surgeons and physicians providing services to Lifesharing." Review of the Recovery Surgeon Credentialing and Responsibilities effective 1/31/14 stated, "An annual review of each surgeon's credentialing records will be performed by the Lifesharing Medical Director. An update of the required documentation is requested every three years and when license expire."