Bois Forte Vermilion Clinic

CLIA Laboratory Citation Details

3
Total Citations
9
Total Deficiencyies
9
Unique D-Tags
CMS Certification Number 24D0933577
Address 1613 Farm Rd S, Tower, MN, 55790
City Tower
State MN
Zip Code55790
Phone(218) 753-2182

Citation History (3 surveys)

Survey - March 16, 2023

Survey Type: Standard

Survey Event ID: MRS311

Deficiency Tags: D2010 D5421 D5217 D6055

Summary:

Summary Statement of Deficiencies D2010 TESTING OF PROFICIENCY TESTING SAMPLES CFR(s): 493.801(b)(2) The laboratory must test samples the same number of times that it routinely tests patient samples. This STANDARD is not met as evidenced by: . Based on observation, document review, and interview with laboratory personnel, the laboratory failed to ensure hematology proficiency testing samples from one of three 2021 PT events were tested consistent with the number of times the laboratory routinely tested patient specimens Findings are as follows: 1. The laboratory performed Hematology testing as confirmed by Testing Personnel 1 (TP1) during a tour of the laboratory on 03/16/23 at 10:05 a.m. An Abbott Cell-Dyn Emerald hematology analyzer was observed as present and available for use during the tour. 2. The laboratory performed proficiency testing (PT) for Hematology using the Medical Laboratory Evaluation (MLE) proficiency testing provider in 2021. 3. Hematology PT samples CL-01 through CL-05 from the 2021 MLE-M1 event were tested on multiple days as indicated on test result documents generated by the Abbott Cell-Dyn Emerald hematology analyzer. See below for date and time of day testing was performed. Sample 02/03/21 02/04/21 CL-01 9:15 3:11 CL-02 9:17 3:15 CL-03 9:18 3:18 CL-04 9:20 3:20 CL-05 9:22 3:28 4. In an interview at 12:14 p.m., TP1 confirmed the above finding and indicated patient specimens would not be tested in this manner. . D5217 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(c)(1) At least twice annually, the laboratory must verify the accuracy of any test or procedure it performs that is not included in subpart I of this part. Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 3 -- This STANDARD is not met as evidenced by: . Based on document review and interview with laboratory personnel, the laboratory failed to perform and document activities used to verify the accuracy of two of two microscopic examinations performed in the laboratory at least twice annually in 2022. Findings are as follows: 1. The laboratory performed Urine Sediment and Skin KOH microscopic examinations as confirmed by Testing Personnel 1 (TP1) during a tour of the laboratory at 10:05 a.m. on 03/16/23. 2. The Laboratory performed proficiency testing using the Wisconsin State Laboratory of Hygiene (WSLH) proficiency testing provider in 2022. 3. Twice annual Urine Sediment and Skin KOH accuracy verification documentation was not found for 2022 during review of WSLH documents and laboratory records. The laboratory was unable to provide the missing accuracy verification documentation upon request. 4. The laboratory performed approximately 35 Urine Sediment examinations and four Skin KOH examinations annually as indicated on Form CMS-116 Clinical Laboratory Improvement Amendments (CLIA) Application for Certification provided by the laboratory on date of survey. 5. In an interview at 12:14 p.m. on 03/16/23, TP1 confirmed the above finding. D5421 ESTABLISHMENT AND VERIFICATION OF PERFORMANCE CFR(s): 493.1253(b)(1) Each laboratory that introduces an unmodified, FDA-cleared or approved test system must do the following before reporting patient test results: (1)(i) Demonstrate that it can obtain performance specifications comparable to those established by the manufacturer for the following performance characteristics: (1)(i)(A) Accuracy. (1)(i) (B) Precision. (1)(i)(C) Reportable range of test results for the test system. (1)(ii) Verify that the manufacturer's reference intervals (normal values) are appropriate for the laboratory's patient population. This STANDARD is not met as evidenced by: . Based on observation, document review, and interview with laboratory personnel, the laboratory failed to complete a performance verification (PV) for the single non- waived test implemented by the laboratory in 2021. Findings are as follows: 1. The laboratory performed Chemistry testing as confirmed by Testing Personnel 1 (TP1) during a tour of the laboratory at 10:05 a.m. on 03/16/23. 2. A Siemens DCA Vantage analyzer was observed as present and available for use during the tour of the laboratory. Microalbumin to Creatinine Ratio (UACR) testing on this analyzer was implemented on 03/04/21 as indicated in laboratory patient testing records. 3. PV documentation for UACR testing on the DCA Vantage was not found during review of laboratory records. The laboratory was unable to provide a PV upon request. 4. The Laboratory Equipment procedure found in the Lab Manual indicated test performance was verified prior to use. A PV procedure was not found in the Lab Manual. 5. The DCA Patient Test Sheet A1C and Microalbumin/Creat indicated 148 patients received UACR testing since implementation on 03/04/21 through date of survey, 03/16/23. See below Year Number of patients tested 2021 42 2022 80 2023 26 6. In an interview at 12:30 p.m. on 03/16/23, TP1 confirmed the above finding. . D6055 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(9) The technical consultant is responsible for evaluating and documenting the performance of individuals responsible for moderate complexity testing whenever test -- 2 of 3 -- methodology or instrumentation changes. The individual's performance must be reevaluated to include the use of the new test methodology or instrumentation prior to reporting patient test results. This STANDARD is not met as evidenced by: . Based on observation, document review, and interview with laboratory personnel, the Technical Consultant (TC) failed to document a competency evaluation for three of three testing personnel prior to testing patient specimens using a new Chemistry test in 2021. Findings are as follows: 1. The laboratory performed Chemistry testing as confirmed by Testing Personnel 1 (TP1) during a tour of the laboratory at 10:05 a. m. on 03/16/23. 2. A Siemens DCA Vantage analyzer was observed as present and available for use during the tour of the laboratory. Microalbumin to Creatinine Ratio (UACR) testing on this analyzer was implemented on 03/04/21 as indicated in laboratory patient testing records. 3. Employee training for new tests was required as established in the QA Policy and Procedure found in the Lab Manual. 4. UACR initial training and competency evaluation documents for tenured Testing Personnel TP1, TP2, and TP3 were not found during review of laboratory records. The laboratory was unable to provide these documents upon request. 5. The DCA Patient Test Sheet A1C and Microalbumin/Creat indicated 148 patients received UACR testing since implementation on 03/04/21 through date of survey, 03/16/23. See below Year Number of patients tested 2021 42 2022 80 2023 26 6. In an interview at 2:25 p.m. on 03/16/23, TP1 confirmed the above finding. . -- 3 of 3 --

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Survey - March 24, 2021

Survey Type: Standard

Survey Event ID: S0GK11

Deficiency Tags: D5407 D5403

Summary:

Summary Statement of Deficiencies 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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Survey - January 9, 2019

Survey Type: Standard

Survey Event ID: PXCZ11

Deficiency Tags: D5211 D5807 D5787

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) scores for 2 results in 2017 and 3 results in 2018. Findings are as follows: 1. The laboratory performed Chemistry and Hematology testing as confirmed by the Testing Personnel 1 (TP1) during a tour of the laboratory on 01/09/19 at 10:05 a.m. The laboratory performed PT using the Medical Laboratory Evaluation (MLE) PT provider. 2. The laboratory received unacceptable PT results from MLE in 2017 and 2018 for the analytes listed below. Chemistry Event Sample Test* Lab MLE result 2017-2 US-3 U.Sed Fiber Mucus strands US-4 U.Sed RBC Granular Cast 2018-1 US- 1 U.Sed Bacteria Fiber Hematology Event Sample Test Lab MLE result 2018-1 HD-4 RBC 2.13 2.15-2.43 HD-4 Lymph 16.6 46.4-60.6 3. Unacceptable PT test result investigations were required within 30 days of result receipt as established in the Laboratory External Proficiency Procedure located in the MLE 2018 PT Program Binder. 4. 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. 5. In an interview on 01/09/19 at 11:45 a.m., TP1 confirmed a documented investigation of the unacceptable results was not performed. * Note U.Sed Urine Sediment microscopic examination RBC Red Blood Cells Lymph Lymphocytes D5787 TEST RECORDS CFR(s): 493.1283(a) 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 -- The laboratory must maintain an information or record system that includes the following: (a)(1) The positive identification of the specimen. (a)(2) The date and time of specimen receipt into the laboratory. (a)(3) The condition and disposition of specimens that do not meet the laboratory's criteria for specimen acceptability. (a)(4) The records and dates of all specimen testing, including the identity of the personnel who performed the test(s). This STANDARD is not met as evidenced by: . Based on document review and interview with laboratory personnel, the laboratory failed to maintain an information or record system (patient testing log) for microscopic examinations. Findings are as follows: 1. The laboratory performs microscopic examinations for Urine Sediment as confirmed by Testing Personnel 1 (TP1) during a tour of the laboratory at 10:05 a.m. on 01/09/19. 2. A patient testing log for microscopic examinations was not present in laboratory records. The laboratory was unable to provide a patient testing log upon request. 3. In an interview on 01/09/19 at 11:00 a.m., TP1 confirmed a manual testing log was not in place for Urine Sediment microscopic examinations. D5807 TEST REPORT CFR(s): 493.1291(d) Pertinent "reference intervals" or "normal" values, as determined by the laboratory performing the tests, must be available to the authorized person who ordered the tests and, if applicable, the individual responsible for using the test results. This STANDARD is not met as evidenced by: . Based on observation, document review and interview with laboratory personnel, the laboratory failed to ensure reference intervals were consistent between a Hematology procedure and a patient test report. Findings are as follows: 1. The laboratory performed Hematology testing as confirmed by Testing Personnel 1 (TP1) during a tour of the laboratory on 01/09/19 at 10:05 a.m. 2. An Abbott Cell-Dyn Emerald hematology analyzer was observed as present and available for use during the tour. 3. Two reference intervals listed in the Hematology Normal Ranges table located in the Emerald Manual were not consistent with those included on the patient test report reviewed on date of survey as indicated below. Patient #3819 - adult female tested on 12/20/18/18 Analyte* Table Report Mid cells Abs 0.2-1.4 01.-1.8 Mid cells % 3-13 0.1-24.8 4. In an interview on 01/09/19 at 12:45 p.m., TP1 confirmed the reference range discrepancies between the Hematology Normal Ranges table and the patient test report. *Note Mid cells Abs Mid cells absolute Mid cells % Mid cells percent -- 2 of 2 --

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