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 03/21/2014
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)
Z0119 QUALIFICATIONS
CFR(s): 486.326(a)(2)

The OPO must develop and implement a written policy that addresses potential conflicts of interest for the OPO's director, medical director, senior management, and procurement coordinators.


This STANDARD is not met as evidenced by:


Based on interview and review of policy and procedures, the OPO did not develop a written policy that addressed potential conflict of interest for the medical director.

Finding includes:

During an interview on 3/19/14, an OPO staff member stated that identification of potential conflict of interest for the medical director was outlined in the policy and procedure for Corporate Compliance/Confidentiality. Review of the document revealed that while it covered all OPO employees as well as members of the board of directors and advisory board, there was no written provision specifically for the medical director.

Review of the personnel record further revealed that while the medical director signed a corporate compliance and confidentiality statement, the document however was completed because of advisory board membership and not as medical director.