| 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) |
| Z0259 | QUALIFICATIONS CFR(s): 486.326(a)(1) The OPO must ensure that all individuals who provide services and/or supervise services, including services furnished under contract or arrangement, are qualified to provide or supervise the services. This STANDARD is not met as evidenced by: Based on record review and interview, two of ten donor staff (donor staff #6 and #9) did not meet the qualifications of their position. The position description for organ clinical supervisor (staff #9) dated March 2010 required CPTC (certified procurement coordinator) within one year of employment. A memo dated April 5, 2010 and signed by the director of organ procurement stated Staff #9 will register for her CPTC exam in June, 2010 and will take the exam immediately after returning from leave in early July, 2010. On April 6, 2010 at 3:30 PM, the director of quality services stated that Staff #9 has been in the supervisory role since August 2008. The position description for staff #6 dated July 2009 required ACLS (advanced cardiac life support) certification. Review of staff #6 employee record on March 31, 2:20 PM with the director of talent management showed that the ACLS for staff #6 expired on May 31, 2006. During an interview on April 6, 2010 at 3:05 PM, the chief operating officer confirmed that staff #6 did not have a current ACLS. |