Bigfork Valley Hospital

CLIA Laboratory Citation Details

3
Total Citations
10
Total Deficiencyies
9
Unique D-Tags
CMS Certification Number 24D0406574
Address 258 Pine Tree Drive, Bigfork, MN, 56628
City Bigfork
State MN
Zip Code56628
Phone(218) 743-3177

Citation History (3 surveys)

Survey - May 2, 2025

Survey Type: Standard

Survey Event ID: 8K1711

Deficiency Tags: D0000 D5403

Summary:

Summary Statement of Deficiencies D0000 The Bigfork Valley Hospital laboratory was found to be out of compliance with the regulations of the Clinical Laboratory Improvement Amendments of 1988 (42 C.F.R. part 493) upon completion of the recertification survey performed on May1, 2025. The following standard-level deficiency was cited: 493.1251 Procedure manual . D5403 PROCEDURE MANUAL CFR(s): 493.1251(b) (b) The procedure manual must include the following when applicable to the test procedure: (b)(1) Requirements for patient preparation; specimen collection, labeling, storage, preservation, transportation, processing, and referral; and criteria for specimen acceptability and rejection as described in 493.1242. (b)(2) Microscopic examination, including the detection of inadequately prepared slides. (b)(3) Step-by- step performance of the procedure, including test calculations and interpretation of results. (b)(4) Preparation of slides, solutions, calibrators, controls, reagents, stains, and other materials used in testing. (b)(5) Calibration and calibration verification procedures. (b)(6) The reportable range for test results for the test system as established or verified in 493.1253. (b)(7) Control procedures. (b)(8)

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Survey - February 1, 2023

Survey Type: Standard

Survey Event ID: HESU11

Deficiency Tags: D5407 D5415 D5431

Summary:

Summary Statement of Deficiencies D5407 PROCEDURE MANUAL CFR(s): 493.1251(d) Procedures and changes in procedures must be approved, signed, and dated by the current laboratory director before use. This STANDARD is not met as evidenced by: . Based on observation, document review, and interview with laboratory personnel, the laboratory failed to ensure one of three performance verifications completed in 2022 was approved, signed, and dated by the laboratory director prior to implementation. Findings are as follows: 1. The laboratory performed Bacteriology testing as confirmed by the General Supervisor (GS) during a tour of the laboratory at 8:05 a.m. on 02/01/23. 2. A Cepheid GeneXpert automated molecular diagnostic system was observed as present and available for use during the tour of the laboratory. The laboratory performed Clostridium difficile (C. diff) testing using this analyzer: 3. The performance verification (PV) for C. diff on the GeneXpert system was completed in January 2022 as indicated in the Cepheid C. Diff Validation records provided by the laboratory. The GS approved the PV results on 01/21/22. 4. The laboratory director's approval signature and date were not found in the PV documents. The laboratory was unable to provide LD approval of the PV upon request. 5. In an interview at 11:45 a.m. on 02/01/23, the GS confirmed the above finding. . D5415 TEST SYSTEMS, EQUIPMENT, INSTRUMENTS, REAGENT CFR(s): 493.1252(c) Reagents, solutions, culture media, control materials, calibration materials, and other supplies, as appropriate, must be labeled to indicate the following: (1) Identity and when significant, titer, strength or concentration. (2) Storage requirements. (3) Preparation and expiration dates. (4) Other pertinent information required for proper use. Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 2 -- This STANDARD is not met as evidenced by: . Based on observation and interview with laboratory personnel, the laboratory failed to label two of two secondary containers used for Hematology manual blood smears. Findings are as follows: 1. The laboratory performed Hematology testing as confirmed by the General Supervisor (GS) during a tour of the laboratory on 02/01/23 at 8:05 a.m. 2. Two unlabeled glass jars containing liquid were observed as available for use in the laboratory during the tour. 3. The Technical Supervisor (TS) stated the unlabeled jars contained Camco Quik Stain II and water. These materials were used for differential staining for manual blood smears. 4. The source bottle for the Camco Quik Stain II was not available on date of survey to verify lot number or expiration date of the stain. 5. In an interview at 8:30 a.m. on 02/01/23, the TS confirmed the above finding. The TS indicated the unlabeled jars were filled on 01/27/23 and the source bottle had been discarded. . D5431 MAINTENANCE AND FUNCTION CHECKS CFR(s): 493.1254(a)(2) For unmodified manufacturer's equipment, instruments, or test systems, the laboratory must perform and document function checks as defined by the manufacturer and with at least the frequency specified by the manufacturer. Function checks must be within the manufacturer's established limits before patient testing is conducted. This STANDARD is not met as evidenced by: . Based on observation, document review, and interview with laboratory personnel, the laboratory failed to ensure function checks for one of three Chemistry analyzers were performed and documented as required from 04/01/21 through 02/01/23. Findings are as follows: 1. The laboratory performed Chemistry testing as confirmed by the General Supervisor (GS) during a tour of the laboratory at 8:05 a.m. on 02/01 /23. 2. An Abbott i-STAT analyzer was observed as present and available for use during the tour. The laboratory used the i-STAT analyzer for Blood Gas testing. The i- STAT was also used as a back up analyzer for Basic Metabolic Panel, Troponin, and BNP testing. 3. The manufacturer required twice annual verification of the i-STAT thermal probe as indicated in the Abbott i-STAT System Manual. 4. Twice annual verification of the i-STAT thermal probe was not established in the I-STAT Procedure found in the laboratory's I-STAT manual. 5. Evidence of thermal probe verification performance between 04/01/21 and 02/01/23 was not found in laboratory records. The laboratory was unable to provide this documentation upon request. 6. In an interview at 3:40 p.m. on 02/01/23, the GS confirmed the above finding and indicated i-STAT thermal probe checks had not been performed. . -- 2 of 2 --

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Survey - December 19, 2018

Survey Type: Standard

Survey Event ID: UBHW11

Deficiency Tags: D5211 D5215 D5403 D5787 D6120

Summary:

Summary Statement of Deficiencies D5211 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(a) The laboratory must review and evaluate the results obtained on proficiency testing performed as specified in subpart H of this part. This STANDARD is not met as evidenced by: . Based on document review and interview with laboratory personnel, the laboratory failed to investigate unacceptable Chemistry and Hematology proficiency testing (PT) results for 4 analytes in 2017 and 4 analytes in 2018. Findings are as follows: 1. The laboratory performed Chemistry and Hematology testing as confirmed by the General Supervisor (GS) during a tour of the laboratory on 12/19/18 at 8:10 a.m. The laboratory performed PT using the American Proficiency Institute (API) PT provider. 2. The laboratory received unacceptable PT results from API in 2017 and 2018 for the analytes listed below. Chemistry Event Sample Test* Lab API result 2017-3 CH-11 Vanc 38.9 25.7-38.7 CH-14 Vanc 10.1 5.9-10.0 2018-2 CH-10 LDL 42 44-67 2018-3 HCG-13 HCG 1264 994-1237 CH-13 LDL 42 15-41 Hematology Event Sample Test Lab API result 2017-1 XE-01 Mono 7.6 7.9-12.2 2017-2 XE-07 Neut 50.5 44.0-50.2 2018-1 XE-03 IG Ab 3.01 2.28-2.95 3. An investigation of the unacceptable PT results was not found during review of laboratory records. The laboratory was unable to provide investigation documentation upon request. 4. In an interview on 12/19/18 at 10:50 a.m., the GS confirmed a documented investigation of the unacceptable results was not performed. * Note Vanc Vancomycin LDL Low-density Lipoprotein HCG Human Chorionic Gonadotropin Mono Monocytes Neut Neutrophils IG Ab IG Absolute D5215 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(b)(2) The laboratory must verify the accuracy of any analyte, specialty or subspecialty Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 4 -- assigned a proficiency testing score that does not reflect laboratory test performance (that is, when the proficiency testing program does not obtain the agreement required for scoring as specified in subpart I of this part, or the laboratory receives a zero score for nonparticipation, or late return or results). This STANDARD is not met as evidenced by: . Based on document review and interview with laboratory personnel, the laboratory failed to verify the accuracy of Microbiology, Chemistry and Hematology proficiency testing (PT) scores when the PT program did not obtain the agreement required for scoring. Findings are as follows: 1. The laboratory performed Microbiology, Chemistry and Hematology testing as confirmed by the General Supervisor (GS) during a tour of the laboratory on 12/19/18 at 8:10 a.m. 2. The laboratory performed PT using the American Proficiency Institute PT provider. 3. Three PT results from 2017 and six PT results from 2018 were not graded due to lack of consensus. See below for sample identifications (ID) and analytes. 2017 Sample ID Analyte UR-06 Levofloxacin UR-06 Piperacillin/tazobactam UR-11 Susceptibility 2018 Sample ID Analyte UDS-02 Opiates CM-15 B-type Natriuretic Peptide CH-11 Low Density Lipoprotein BFM-02 Body Fluid Microscopy BL-01 Blood Culture UP-06 Piperacillin /tazobactam 4. The API expected results data summaries were not present in laboratory records. Evaluations for accuracy of the non-graded results were not found during review of laboratory documents. The laboratory was unable to provide evaluations of non-graded results upon request. 5. In an interview on 12/19/18 at 9:40 a.m., the GS confirmed the non-graded PT results had not been evaluated for accuracy. D5403 PROCEDURE MANUAL CFR(s): 493.1251(b) The procedure manual must include the following when applicable to the test procedure: (1) Requirements for patient preparation; specimen collection, labeling, storage, preservation, transportation, processing, and referral; and criteria for specimen acceptability and rejection as described in 493.1242. (2) Microscopic examination, including the detection of inadequately prepared slides. (3) Step-by-step performance of the procedure, including test calculations and interpretation of results. (4) Preparation of slides, solutions, calibrators, controls, reagents, stains, and other materials used in testing. (5) Calibration and calibration verification procedures. (6) The reportable range for test results for the test system as established or verified in 493.1253. (7) Control procedures. (8)

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