Summary:
Summary Statement of Deficiencies D0000 An announced CLIA recertification survey was conducted at ACE Care on December 10, 2019 by the Virginia Department of Health's Office of Licensure and Certification. The laboratory was surveyed under 42 CFR part 493 CLIA Regulations. The specific deficiency is as follows: D3011 FACILITIES CFR(s): 493.1101(d) Safety procedures must be established, accessible, and observed to ensure protection from physical, chemical, biochemical, and electrical hazards, and biohazardous materials. This STANDARD is not met as evidenced by: Based on a tour of the laboratory, review of the the laboratory's policy and procedure manual, and an interview with the primary testing personnel, the laboratory failed to have a policy for the monitoring of the Honeywell Eye Saline Wall Station saline solution from December 2017 to the date of the survey on December 10, 2019. Findings include: 1. A tour of the laboratory at approximately 9:30 AM revealed a Honeywell Eye Saline Wall Station mounted to the wall above the laboratory sink with a saline solution (lot number 15254-21) with an expiration date of August 2018. 2. Review of the laboratory policy and procedure manual revealed a lack of a policy for the monitoring of the Honeywell Eye Saline Wall Station saline solution. The surveyor requested a policy for the monitoring of the saline solution. The laboratory provided no policy for review. 3. In an interview with the primary testing personnel and Laboratory Director at approximately 12:30 PM, the above findings were confirmed. Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 1 --