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)
Z0307 REQUESTING CONSENT
CFR(s): 486.342(b)

If an OPO does not request consent to donation because a potential donor consented to donation before his or her death in a manner that satisfied applicable State law requirements in the potential donor's State of residence, the OPO must provide information about the donation to the family of the potential donor, as requested.


This STANDARD is not met as evidenced by:


Based on record review and interview, the OPO did not ensure that information about donation was given to the family of a potential donor who had, prior to his or her death, given consent to donation.

Finding includes:

Review of two of 2 records of donors who had first-person consent revealed the lack of evidence that their family was given information regarding donation. During an interview on 3/17/10, an OPO staff member stated that the same information was given to family members of potential donors whether or not a first-person consent was executed. The staff member added that the "Document of Gift" form as well as a "supplemental" form should also indicate that information was given, and that by signing both forms, the family member acknowledges receipt of the information. The staff also stated that case notes should also document that donation information was given to the family member.

Review of the "Document of Life" form revealed that in addition to verification of donor registry, the form also documented family notification of the presence of first-person consent. And while the "supplemental" form contains a provision that when checked "yes" authorizes the OPO to contact the family member and "my family by mail, phone, or voice message in order to provide support, education and outreach," there was no documentation about what information regarding donation was provided. (Reference Donors 7 and 16.)