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 03/29/2018
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)
Z0120 QUALIFICATIONS
CFR(s): 486.326(a)(3)

The OPO must have credentialing records for physicians and other practitioners who routinely recover organs in hospitals under contract or arrangement with the OPO and ensure that all physicians and other practitioners who recover organs in hospitals with which the OPO has agreements are qualified and trained.


This STANDARD is not met as evidenced by:
Based on interview and on one of 15 donor records reviewed, the OPO did not ensure that it had credentialing records to ensure that all physicians and other practitioners who recover organs in hospitals with which the OPO had agreements were qualified and trained.



Finding includes:



During an interview on 3/29/18, an organ allocation staff member (OPO Staff 1) stated that the OPO uses the ACIN (AOPO Credentials Information Network) to ascertain the credentials of physicians that recover organs on behalf of the OPO. The ACIN, which is maintained by the AOPO (Association of Organ Procurement Organizations) is an online database that enables the OPO to quickly verify the credentials and/or qualifications and training of physicians prior to organ recovery.



Review of the clinical record revealed that Donor A was an organ donor on 10/12/16 and that his heart was recovered.



The ACIN database noted that Physician A, the recovering physician, was credentialed to recover heart and lungs and that his status was "Active" with an approval date of 7/16/12. Further review however, revealed that while Physician A's license number was posted, the database did not include the license expiration date to ensure that it was current at the time of recovery.



Further review of the clinical record revealed that Donor 2 was also a liver donor. Review of the ACIN profile which was created by another OPO indicated that Physician B, who performed the recovery, was credentialed to recover liver, kidneys, and pancreas. The profile further noted that the physician's status was "Active" and had an approval date of 7/17/17. While the physician's medical license number was posted, the expiration date however was not provided to ensure that it was current.



During the same interview, OPO Staff 1 explained that the OPOs who provided the physicians' credentials on the ACIN database should have included and/or updated the information. In the same interview, another administrative staff member (OPO Staff 2) added that OPO practice was to visually inspect the physician's actual license prior to organ recovery. However, documentation of this process was not available in the donor record.