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 06P001 (X3) Date Survey Completed 04/06/2010
Name of Provider or Supplier Donor Alliance Street Address, City, State 200 Spruce St Suite 200, Denver, CO
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)
Z0227 ADMINISTRATION AND GOVERNING BODY
CFR(s): 486.324(a)(1)

While an OPO may have more than one board, the OPO must have an advisory board that has both the authority described in paragraph (b) of this section and the following membership: (1) Members who represent hospital administrators, either intensive care or emergency room personnel, tissue banks, and voluntary health associations in the OPO's service area.




Based on record review and interview, the organ procurement organization (OPO) failed to have one of four required members on the advisory board (tissue bank representative).

The OPO advisory board membership list for 2010 identified the tissue medical director as ex-officio member. Another representative from a tissue bank was not identified on the list of members.

The OPO Advisory board of directors meeting summary dated November 3, 2009 identified the tissue medical director under the category of " others present " and not as a member.

The Advisory Board by laws adopted as of April 27, 2009 stated " The Advisory Board shall be comprised of Members who fulfill the regulatory requirements ..... Members who represent hospital administrators, either intensive care or emergency room personnel, tissue banks, and voluntary health associations in the OPO ' s service area. "

On April 6, 2010 at 1:20 PM the director of quality systems stated that the tissue medical director is the only tissue representative (on the advisory board).

During the survey exit on April 6, 2010 at 5:25 PM, the surveyor requested additional information to show that the advisory board included a member from a tissue bank. The chief executive officer, the director of quality systems, and the chief operating officer were present. A voting member representing the tissue banks was not identified.