Dermatology Associates Of Tallahassee Pa

CLIA Laboratory Citation Details

2
Total Citations
4
Total Deficiencyies
3
Unique D-Tags
CMS Certification Number 10D0270011
Address 1707 Riggins Rd, Tallahassee, FL, 32308
City Tallahassee
State FL
Zip Code32308
Phone(850) 877-4134

Citation History (2 surveys)

Survey - February 2, 2024

Survey Type: Standard

Survey Event ID: B2SR11

Deficiency Tags: D0000 D5209

Summary:

Summary Statement of Deficiencies D0000 An onsite announced CLIA recertification survey was conducted at Dermatology Associates of Tallahassee PA, a laboratory in Tallahassee, FL, on 02/02/2024. The laboratory is not in compliance with 42 CFR Part 493, Requirements for Laboratories. 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: 49973 Based on review of the Employee Training and Evaluation Standard Operating Procedure (SOP) and interview with the Laboratory Manager (LM), the laboratory failed to have an approved policy or documentation for the competency assessment of testing personnel (TP) for 2022-2024. The findings include: During a review of employee trainings, there was no documentation to to verify that TP #B received any competency assessments during 2022 or 2023. During an interview on 02/02/24 at 11: 15 a.m., the LM verified that TP #B had never been competency assessed. Upon review of the laboratory's Employee Training and Evaluation SOP (last approved by the Laboratory Director in 2024), there was no competency assessment processes for testing personnel listed. 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 - January 31, 2020

Survey Type: Standard

Survey Event ID: I82L11

Deficiency Tags: D5413 D0000

Summary:

Summary Statement of Deficiencies D0000 An announced CLIA recertification survey was conducted at Dermatology Associates of Tallahassee PA on January 31, 2020. The laboratory is not in compliance with 42 CFR Part 493, Requirements for Laboratories. The following is a description of the standard level deficiencies: D5413 TEST SYSTEMS, EQUIPMENT, INSTRUMENTS, REAGENT CFR(s): 493.1252(b) The laboratory must define criteria for those conditions that are essential for proper storage of reagents and specimens, accurate and reliable test system operation, and test result reporting. The criteria must be consistent with the manufacturer's instructions, if provided. These conditions must be monitored and documented and, if applicable, include the following: (1) Water quality. (2) Temperature. (3) Humidity. (4) Protection of equipment and instruments from fluctuations and interruptions in electrical current that adversely affect patient test results and test reports. This STANDARD is not met as evidenced by: Based on record review and interview with the Histotechnologist, the Laboratory failed to document humidity for 2 of 2 (2018 - 2019 ) years reviewed. Findings Included: Review of temperature logs revealed no humidity documented from January 2018 through December 2019. During an interview on 01/31/2020 at 10:30 AM, Histotechnologist # 3 confirmed that the humidity was not documented. 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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