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 05/22/2014
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)
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 record review and interview, the OPO did not develop policy and procedures that addressed potential conflict of interest for the OPO's executive director and medical director.

Finding includes:

Review of the OPO's corporate compliance document revealed that the policy and procedure for conflict of interest did not identify or address potential conflict of interest for employees who were also members of the governing body or medical advisory board. Review of the declaration forms for both employees and members of the board revealed different disclosure forms.

During an interview on 5/21/14, an OPO staff member stated that while the policy and procedure did not specify this, that beginning in 2014, all OPO employees who were also members of the board, such as the executive director (on the governing board), and medical director (on the medical advisory board) will have to complete 2 disclosures yearly. The staff added that for 2014, for example, the executive director had completed both employee and governing body disclosures.