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 05P005 (X3) Date Survey Completed 04/16/2010
Name of Provider or Supplier Donor Network West Street Address, City, State 12667 Alcosta Blvd, Suite 500, San Ramon, 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, the OPO did not have bylaws for each board that addressed potential conflict of interest.

Findings include:

1. Review of the OPO's "Amended and Restated Bylaws" revealed the lack of provision that identified and addressed potential conflict of interest for members of the medical advisory board.

2. Article XI of the same bylaw noted that "The Board of Directors shall adopt and periodically review and, as necessary, revise, a policy governing conflict of interest." The bylaw however did not include provisions for the identification of potential conflict of interest; did not specify the frequency of any review or conditions for revisions; and did not include procedures for how potential conflict of interest would be addressed.