| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 05P004 | (X3) Date Survey Completed 04/02/2010 |
| Name of Provider or Supplier Sierra Donor Services | Street Address, City, State 1760 Creekside Oaks Drive, Suite 160, Sacramento, 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 OPO did not have bylaws for each board that addressed potential conflict of interest. Finding includes: During an interview on 3/31/10, an administrative staff member stated that the OPO had developed and approved policies and procedures that addressed potential conflict of interest for members of the medical advisory and governing boards, as well as for employees. Review of the governing board as well as the medical advisory board bylaws however, revealed that the bylaws did not include a provision that identified and addressed potential conflict of interest. In the same interview on 3/31/10, the staff member stated that the advisory board bylaw required advisory board members to "refrain from engaging in personal activities which would injure or take advantage of the organization or are in any way contrary to the interests of the corporation." While the staff member added that this statement in the bylaw addressed potential conflict of interest, it did not identify situations that constituted conflict of interest and steps the OPO would take to address any potential conflict of interest. |