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)
Z0262 STAFFING
CFR(s): 486.326(b)(1)

The OPO must provide sufficient coverage, either by its own staff or under contract or arrangement, to assure both that hospital referral calls are screened for donor potential and that potential donors are evaluated for medical suitability for organ and/or tissue donation in a timely manner.


This STANDARD is not met as evidenced by:


Based on record review and interview, the OPO did not ensure that onsite evaluation of a potential donor was conducted within 1 - 2 hours as required by policies and procedures.

Findings include:

1. On 3/17/10 at 3:40 p.m. a record review of Donor 6 Referral Information revealed that a referral was made on 1/08/08 at 12:00 p.m. and the OPO arrived on 1/08/08 at 2:45 p.m. for a response time of 2 hours and 45 minutes.

2. On 3/17/2010 at 4:05 p.m., a record review of Donor 2 Referral Information notes that a referral was made on 1/14/2007 at 4:24 p.m. and the OPO arrived at 6:45 p.m. for a response time of 2 hours and 25 minutes.

Review of the OPO's policy and procedure on "Response to Referrals" required that "on site response to a referral is expected within 1 to 2 hours. If a delayed response is expected, the AOC (administrator on-call) and hospital will be notified."

During an interview on 3/17/10, an OPO staff stated that any delay response was also documented in the donor record including case notes by the staff assigned to conduct the onsite evaluation. Review of the donor records however did not reveal any such documentation; or that the AOC and the hospital were informed.