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 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)
Z0261 QUALIFICATIONS
CFR(s): 486.36(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 record review and interview, the OPO did not have credentialing records to ensure that physicians and other practitioners who recover organs were qualified and trained.

Finding includes:

In three donation cases where organ recovery was performed by a surgeon outside of the OPO's designated service area, review of donor records revealed the lack of documentation that the surgeon's credential was verified prior to organ recovery to ensure that he or she was trained and qualified.

Furthermore, during an interview on 4/01/10, a staff member stated that the OPO relied on a database made available by the AOPO (Association of Organ Procurement Organizations) in October, 2009 where OPOs can verify the credential of each surgeon prior to organ recovery. The staff member added that the database (AOPO Credentialing Information Network-ACIN ) contained credentialing information on surgeons supplied by their transplant centers on a voluntary basis.

Review of an ACIN printout revealed that while the surgeon's license number and organs for which the surgeon has, accordingly, been privileged to recover were listed, the expiration date of the license and privileges was not available to ensure that credentialing information was current.