Summary:
Summary Statement of Deficiencies D5805 TEST REPORT CFR(s): 493.1291(c) The test report must indicate the following: (c)(1) For positive patient identification, either the patient's name and identification number, or a unique patient identifier and identification number. (c)(2) The name and address of the laboratory location where the test was performed. (c)(3) The test report date. (c)(4) The test performed. (c)(5) Specimen source, when appropriate. (c)(6) The test result and, if applicable, the units of measurement or interpretation, or both. (c)(7) Any information regarding the condition and disposition of specimens that do not meet the laboratory's criteria for acceptability. This STANDARD is not met as evidenced by: . Through a review of ten randomly selected medical records and interviews with laboratory staff, it was determined the laboratory reports for Complete Blood Counts (CBC) failed to include the name and address where the testing was performed. As evidenced by: A. A review of ten randomly selected patient medical records revealed that all (10 of 10) complete blood counts (CBC) failed to include the name and address of the laboratory performing the tests. B. In an interview at 11:25 on 05/02 /2019, the technical consultant (as listed on form CMS-209) confirmed the lack of laboratory name and address on CBC test reports. 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 --