Center For Skin Surgery Laboratory

CLIA Laboratory Citation Details

3
Total Citations
14
Total Deficiencyies
7
Unique D-Tags
CMS Certification Number 23D2046931
Address 46325 W 12 Mile Road Suite 370, Novi, MI, 48377
City Novi
State MI
Zip Code48377
Phone(248) 773-3640

Citation History (3 surveys)

Survey - August 26, 2024

Survey Type: Standard

Survey Event ID: QEU911

Deficiency Tags: D5209 D5209

Summary:

Summary Statement of Deficiencies D5209 PERSONNEL COMPETENCY ASSESSMENT POLICIES CFR(s): 493.1235 As specified in the personnel requirements in subpart M, the laboratory must establish and follow written policies and procedures to assess employee and, if applicable, consultant competency. This STANDARD is not met as evidenced by: . Based on record review and interviews with Testing Personnel #3, the laboratory failed to follow its competency assessment policies when assessing testing personnel for one (Testing Personnel #3) of three testing personnel listed on Form CMS-209. Findings include: 1. An interview on 8/26/24 at 9:15 am with Testing Personnel #3 revealed they were performing specimen gross examinations on skin tissue specimens processed by the laboratory. 2. A review of the laboratory's "Competency Testing Policy" revealed a section stating, "The procedures for evaluation of the competency of the staff must include but not be limited to: 1. Direct observation of various phases of testing. 2. Monitoring the specimen preparation. 3. Review of logs and records. 4. Direct observation of performance of instrument maintenance and function checks. 5. Assessment of problem solving skills. 6. Evaluation and documentation of performance annually unless methodology has changed." 3. A review of Testing Personnel #3's competency assessments revealed a lack of direct observation of gross specimen examination testing and assessment of problem-solving skills. 4. An interview on 8/26/24 at 12:09 pm with Testing Personnel #3 confirmed competency assessments lacked direct observation of gross specimen examination testing and assessment of problem-solving skills. 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 - August 10, 2022

Survey Type: Standard

Survey Event ID: H5T811

Deficiency Tags: D5787 D5801 D5431 D5787 D5801

Summary:

Summary Statement of Deficiencies 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 lack of documentation and interview with Testing Personnel (TP) #2, the laboratory failed to perform and document the function checks as required for the room temperature for 18 (March 2021 to August 2022) of 18 months of patient testing. Findings include: 1. A record review on 8/10/2022 at 11:30 am revealed lack of documentation of the room temperature for 18 of 18 months of patient testing. 2. A record review of the "Quality Control Program" policy, under section Test Methods, Equipment, Reagents, Materials and Supplies states "All equipment within the laboratory will be properly maintained according to the manufacturer's specification. "All maintenance and repairs will be recorded and maintained by the laboratory personnel and will be review by the Laboratory Director on a periodic basis." 3. An interview on 8/10/2022 at 6/23/2022 at 11:30 am, TP2 confirmed the laboratory failed to perform and document the room temperature. D5787 TEST RECORDS CFR(s): 493.1283(a) 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 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 -- who performed the test(s). This STANDARD is not met as evidenced by: . Based on record review and interview with Testing Personnel (TP) #2, the laboratory failed to document the time of specimen receipt into the laboratory for 2 (L-21-123 and M-22-061) of 18 Mohs' cases reviewed. Findings include: 1. A review of 18 Mohs' cases revealed 2 cases did not have the time received in the laboratory documented on the Mohs' map as follows: a. K-21-123, stages I and II b. M-22-061, stages I, II, III, and IV 2. An interview on 8/10/2022 at 11:30, TP2 confirmed the time of specimen receipt in the laboratory had not been documented. ***Repeat Deficiency from the 9/17/2018 survey*** D5801 TEST REPORT CFR(s): 493.1291(a) The laboratory must have an adequate manual or electronic system(s) in place to ensure test results and other patient-specific data are accurately and reliably sent from the point of data entry (whether interfaced or entered manually) to final report destination, in a timely manner. This includes the following: (a)(1) Results reported from calculated data. (a)(2) Results and patient-specific data electronically reported to network or interfaced systems. (a)(3) Manually transcribed or electronically transmitted results and patient-specific information reported directly or upon receipt from outside referral laboratories, satellite or point-of-care testing locations. This STANDARD is not met as evidenced by: . Based on record review and interview with Testing Personnel (TP) #2, the laboratory failed to establish a system to ensure the transcribed Mohs' surgery site was accurately reported for 3 (M-21-702, M-22-165, and M-22-233) of 18 Mohs cases reviewed. Findings include: 1. A record review revealed for 3 of 18 Mohs' cases reviewed, the surgical site on the pre-op biopsy report, the Mohs' map, Mohs' log, and the final report in the electronic medical record (EMR) system are not consistently transcribed throughout the Mohs' survey process as follows: a. M-21-702 performed on 12/18 /2021 i. Pre-op biopsy report, Mohs' map, and the EMR report - left inferior lateral forehead ii. Mohs' log - left lateral forehead b. M-22-165 performed on 4/18/2022 i. Pre-op biopsy report, Mohs' map, and the EMR report - left inferior lateral forehead ii. Mohs' log - left inferior forehead c. M-22-233 performed on 6/13/2022 i. Pre-op biopsy report, Mohs' map, and the EMR report - left inferior central malar cheek ii. Mohs' log - left inferior central cheek 2. An interview on 8/10/2022 at 11:30 am, TP2 confirmed the locations on the pre-op biopsy report, Mohs' map, Mohs' log, and the final EMR report were not consistent with the original biopsy site throughout the survey process. -- 2 of 2 --

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Survey - September 17, 2018

Survey Type: Standard

Survey Event ID: J4VQ11

Deficiency Tags: D5411 D5415 D5417 D5415 D5417 D5787 D5787

Summary:

Summary Statement of Deficiencies D5411 TEST SYSTEMS, EQUIPMENT, INSTRUMENTS, REAGENT CFR(s): 493.1252(a) Test systems must be selected by the laboratory. The testing must be performed following the manufacturer's instructions and in a manner that provides test results within the laboratory's stated performance specifications for each test system as determined under 493.1253. This STANDARD is not met as evidenced by: . Based on operator's manual review and interview, the laboratory failed to follow the manufacturer's operator's manual to monitor and record the humidity readings in the laboratory for 24 (September 2016 to September 2018) of 24 months reviewed to ensure reliable Leica CM 1510S cryostat operation. Findings include: 1. On September 17, 2018 at 11:00 AM, document review of the maintenance log for temperatures revealed there was no monitoring and documenting of the humidity for 24 (September 2016 to September 2018) of 24 months reviewed. 2. During the interview on September 17, 2018 at 11:00 AM, the laboratory director confirmed the humidity readings were not monitored and documented. 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. This STANDARD is not met as evidenced by: 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 -- . Based on observation and interview, the laboratory failed to label the Mohs' tissue marking dyes (yellow, green, red, and blue) with the contents, storage requirements, preparation, and expiration dates for the poured off inks stored in smaller containers. Findings include: 1. On September 17, 2018 at approximately 9:20 AM during a tour of the laboratory, the surveyor observed the Mohs' tissue marking dyes (yellow, green, red, and blue) poured off into smaller containers. There was no documentation on the containers with the contents, storage requirements, preparation, or expiration dates when the dyes were poured into the containers. 2. During the interview on September 17, 2018 at approximately 9:20 AM, the laboratory director confirmed the poured off marking dye containers were no labeled. 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 observation and interview, the laboratory failed to use nine (violet, green, blue, black, orange, red, red, and yellow) of 13 Mohs' tissue marking dyes before the manufacturer's expiration date. Findings include: 1. During a tour of the laboratory on September 17, 2018 at approximately 9:20 AM, the surveyor observed the Mohs' tissue marking dyes located in the cupboard in use past the manufacturer's expiration dates recorded on the label as follows: a. violet - lot 37796 expiration date 02/2017 b. green - lot 044507 expiration date 01/2018 c. yellow - lot 05089 expiration date 09 /2016 d. blue - lot 044802 expiration date 02/2018 e. black - lot 36886 expiration date 03/2017 f. orange - lot 38887 expiration date 04/2017 g. red - lot 046279 expiration date 04/2018 h. red - lot 7137 expiration date 08/2018 i. yellow - lot 044509 expiration date 01/2018 2. During the interview on September 17, 2018 at approximately 9:20 AM, the laboratory director confirmed the dyes had exceeded the manufacturer's expiration dates. D5787 TEST RECORDS CFR(s): 493.1283(a) 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 record review and interview, the laboratory failed to 1) maintain a record system that included the identity of the testing personnel performing the Mohs' microscopic tissue examination for two (#14 and #16) of 20 patient charts audited and the microscopic frozen section interpretation for one (#18) of 20 patient charts audited and 2) the date and time of specimen receipt into the laboratory for the Mohs' tissue and the frozen section specimens for 20 (#1 - #20) of 20 patient charts audited. Findings include: 1. On September 17, 2018 at 12:00 PM, record review of patients -- 2 of 3 -- charts revealed the laboratory did not include the identity of the testing personnel who performed the Mohs' microscopic tissue examination and the frozen section interpretation for two of 20 and one of 20 patient charts audited. 2. On September 17, 2018 at 12:00 PM, record review revealed the laboratory did not have any record of the time the Mohs' tissue and the frozen section specimens were received into the laboratory for examination. 3. During the interview on September 17, 2018 at 12:00 PM, the laboratory director confirmed the identity of the testing personnel and the time of specimen receipt into the laboratory was not available on the patient's final test reports. -- 3 of 3 --

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