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 05P002 (X3) Date Survey Completed 03/19/2010
Name of Provider or Supplier Onelegacy Street Address, City, State 221 S Figueroa St, Suite 500, Los Angeles, 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)
Z0235 ADMINISTRATION AND GOVERNING BODY
CFR(s): 486.324(d)

The OPO must have bylaws for each of its board(s) that address potential conflicts of interest, length of terms, and criteria for selecting and removing members.


This STANDARD is not met as evidenced by:


Based on record review and interview, the organ procurement organization advisory board bylaws did not address potential conflicts of interest for the bylaws amended 2/09/2010.

Finding includes:

Review on 3/17/10 of the written bylaws of the OPO's advisory board amended on 2/09/10 did not include a provision for identifying and addressing potential conflicts of interest for advisory board members.

During an interview on 3/18/10, an OPO staff member stated that while the OPO had a policy on conflict of interest, the advisory board bylaws however did not include a provision for identifying potential conflicts of interest and how these could be addressed for members of the advisory board.