Angeline Elizabeth Kirby Memorial Hlth Ctr

CLIA Laboratory Citation Details

2
Total Citations
4
Total Deficiencyies
2
Unique D-Tags
CMS Certification Number 39D0657582
Address 71 North Franklin Street, Wilkes Barre, PA, 18701
City Wilkes Barre
State PA
Zip Code18701
Phone(570) 822-4278

Citation History (2 surveys)

Survey - December 11, 2024

Survey Type: Standard

Survey Event ID: 4IOQ11

Deficiency Tags: D0000 D0000

Summary:

Summary Statement of Deficiencies D0000 An onsite recertification survey conducted on December 11, 2024, found the Angeline Elizabeth Kirby Memorial Health Center laboratory in compliance with 42 CFR Part 493, Requirements for Laboratories. 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 --

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Survey - March 22, 2023

Survey Type: Standard

Survey Event ID: 7YS911

Deficiency Tags: D5775 D5775

Summary:

Summary Statement of Deficiencies D5775 COMPARISON OF TEST RESULTS CFR(s): 493.1281(a)(c) (a) If a laboratory performs the same test using different methodologies or instruments, or performs the same test at multiple testing sites, the laboratory must have a system that twice a year evaluates and defines the relationship between test results using the different methodologies, instruments, or testing sites. (c) The laboratory must document all test result comparison activities. This STANDARD is not met as evidenced by: Based on lack of documentation and interview with the technical supervisor (TS), the laboratory failed to evaluate twice a year the relationship between test results for 2 of 2 Atomic Absorption Spectrophotometers from 01/14/2021 to the day of the survey. Findings include: 1. On the day of the survey, 03/22/2023 at 11:00 am, the laboratory could not provide documentation of the biannual comparison of test results between 2 of 2 Perkin Elmer PinAAcle 900 Atomic Absorption Spectrophotometers for lead testing performed from 01/14/2021 to 03/22/2023. 2. The laboratory performed 14,760 lead examinations in 2022 (annual volume listed on CMS-116). 3. The TS confirmed the finding above on 03/22/2023 at 11:15 am. 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 --

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