Summary:
Summary Statement of Deficiencies D0000 At the time of the announced, onsite recertification survey, Baptist Primary Care Inc was found to not be in compliance with the CLIA laboratory requirements of 42 CFR 493. D5417 TEST SYSTEMS, EQUIPMENT, INSTRUMENTS, REAGENT CFR(s): 493.1252(d) Reagents, solutions, culture media, control materials, calibration materials, and other supplies must not be used when they have exceeded their expiration date, have deteriorated, or are of substandard quality. This STANDARD is not met as evidenced by: Based on record review and staff interview, the facility failed to ensure urine culture plates were not expired prior to being used for patient testing. Five patients were tested with expired Hardy Chrome and Mueller Hinton plates used for Urine Cultures. The findings include: 1. The record review of the laboratory worksheet titled "Uroplate Log" showed one patient was tested on 2/4/22 and 2/16/22 using Hardy Chrome media with lot number 495501 and expiration date of 2/3/22. One patient was tested on 1/16/23 and 1/19/23 using Hardy Chrome media with lot number 515605 and expiration date of 1/12/23. 2. The record review of the laboratory worksheet titled "Uroplate Log" showed one patient was tested on 3/8/22 using Mueller Hinton media with lot number 141423 and expiration date of 3/3/22. One patient was testing on 1/9 /23 using Mueller Hinton media with lot number 148436 and expiration date of 1/18 /23. During an interview on 6/5/23 at 1:45pm with Testing Person A, it was confirmed the 5 patients were tested using expired culture media. 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 --