District Health Center 1

CLIA Laboratory Citation Details

4
Total Citations
16
Total Deficiencyies
8
Unique D-Tags
CMS Certification Number 39D0701535
Address 1930 South Broad Street, 2nd Floor, Unit #30, Philadelphia, PA, 19145
City Philadelphia
State PA
Zip Code19145
Phone(215) 685-6570

Citation History (4 surveys)

Survey - October 3, 2024

Survey Type: Standard

Survey Event ID: QK7D11

Deficiency Tags: D3009 D5413 D3009 D5413

Summary:

Summary Statement of Deficiencies D3009 FACILITIES CFR(s): 493.1101(c) The laboratory must be in compliance with applicable Federal, State, and local laboratory requirements. This STANDARD is not met as evidenced by: Based on document review and interview with the Laboratory Director (LD), the LD failed to be present for a reasonable period of each working day in each laboratory for which he was director from 01/01/2017 to 10/03/2024 as required by Pennsylvania (PA) state regulations. Findings include: 1. The PA State regulation 5.22 (g) states: "A director shall be present for a reasonable period of each working day in each laboratory for which he is director." 2. Review of the Application for Approval to Direct more than Two Clinical Laboratories (Exception to 5.22) form, revealed the LD currently oversees 10 compliance laboratories (39D0701535) throughout multiple sites in the state of PA. 3. During an interview on 10/03/2024 at 12:20 pm, the LD confirmed he is on-site a few times annually. 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. 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 lack of documentation and interview with the Quality Officer (QO), the laboratory failed to monitor and document room temperature and humidity to ensure operating conditions were met for reliable test system operation and test result reporting of microscopic slide examinations performed in microbiology in 2022, 2023 and 2024. Findings include: 1. The Philadelphia Department of Public Health Laboratory Services Quality Plan policy states, "For all areas that have room temperature dependent reagents and supplies, daily room temperature monitoring is required." 2. Review of the Leica DM 750 microscope manufacturer's instructions revealed the technical specifications for ambient operating temperatures are 10-40 C and 20 -90% relative humidity. 3. On the day of the survey, 10/03/2024, the laboratory failed to provide documentation of the monitoring of room temperature and humidity to ensure operating conditions were met when Trichomonas (wet prep) and potassium hydroxide (KOH) microscopic examinations were performed in 2022, 2023 and 2024. 4. The QO confirmed the above findings on 10/03/2024 at 12:20 pm. -- 2 of 2 --

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Survey - September 8, 2022

Survey Type: Standard

Survey Event ID: G5WL11

Deficiency Tags: D5215 D6046 D5215 D6046

Summary:

Summary Statement of Deficiencies D5215 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(b)(2) The laboratory must verify the accuracy of any analyte, specialty or subspecialty 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 review of the American Proficiency Institute (API) proficiency testing (PT) records and interview with the Quality Assuarance Officer (QA), the laboratory failed to verify the accuracy for 1 of 5 Gram Stain PT results in 2022. Findings Include: 1. On the day of survey, 09/08/2022 at 09:40 am, review of 2022 API proficiency testing records revealed that the laboratory did not verify the accuracy for the following analyte that was not graded by the proficiency testing agency: - API 2022 Microbiology- 1st Event: Gram Stain sample GS-05 was not graded due to non consensus. 2. The QA Officer confirmed the findings above on 09/08/2022 around 11: 00 am. D6046 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(8) (b) The technical consultant is responsible for-- (b)(8) Evaluating the competency of all testing personnel and assuring that the staff maintain their competency to perform test procedures and report test results promptly, accurately and proficiently. 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 2 -- Based on review of the competency assessment (CA) records and interview with the Technical Consultant (TC) #1, the TC failed to assess 8 of 8 testing personnel (TP) for each assay in mycology and parasitology microscopic examinations performed in 2021 and 2022. Findings Include: 1. On the day of Survey, 09/08/2022 at 09:46 a.m., review of the competency assessment records revealed, the forms used to document competency did not separate the two microscopic examinations for Potassium Hydroxide (KOH) Mycology and Wet Mounts (Trichomonas) Parasitology for 8 of 8 TP in 2021 and 2022. 2. The TC confirmed the finding above on 09/08/2022 at 11:35 a.m. -- 2 of 2 --

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Survey - September 10, 2020

Survey Type: Standard

Survey Event ID: QBMD11

Deficiency Tags: D2009 D5209 D6018 D2009 D5209 D6018

Summary:

Summary Statement of Deficiencies D2009 TESTING OF PROFICIENCY TESTING SAMPLES CFR(s): 493.801(b)(1) The individual testing or examining the samples and the laboratory director must attest to the routine integration of the samples into the patient workload using the laboratory's routine methods. This STANDARD is not met as evidenced by: Based on review of American Proficiency Institute (API) proficiency testing (PT) records and interview with the Quality Assessment Officer (QAO), the Laboratory Director (LD) failed to sign 10 of 10 PT attestation statements reviewed from 2018 to 2020. Findings include: 1. The API Attestation Statement Signature page states, "Testing personnel and the laboratory director (or designee) must physically sign an attestation statement for all PT results" 2. On the day of survey, 09/10/2020, review of API PT records revealed, the following API PT attestation statement documents were not signed by the LD: - 2018: Event #3, Hematology/coagulation. Event #3, Microbiology. - 2019: Event#1, Event#2, Event #3: Hematology/coagulation Event#1, Event#2, Event #3: Microbiology - 2020: Event #1: Hematology/coagulation Event #1: Microbiology 3. During an interview on 09/10/2020 at 12:20 p.m. the Quality Assessment Officer stated the laboratory director had a saved electronic signature with API for the attestation statement. 4. The API Quality and Compliance manager was contacted on 9/17/2020, she stated that the laboratory director/designee must physically signed the attestation statement and keep the records on site. 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, 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 -- consultant competency. This STANDARD is not met as evidenced by: A. Based on review of the laboratory's Administrative Policy and Procedure Manual Competency Assessment Program, and interview with the Quality Assessment Officer (QAO), the laboratory failed to have a competency assessment (CA) policy for the 1 of 2 Clinical Consultant, and 1 of 1 Technical Consultant (on the CMS 209 form, listed as personnel #2 and #3) for their supervisory responsibilities from 2018 to the date of survey. Findings include: 1. On the day of survey, 09/10/2020, the QAO could not provide a CA policy to assess the competency of 1 of 2 CC (personnel #2) and 1 of 1 TC (personnel #3) for their supervisory responsibilities in 2018,2019, and 2020 2. The Quality Assessment Officer confirmed the finding above on 09/10/2020 around 10:30 am. B. Based on review of the laboratory's Administrative Policy and Procedure Manual Competency Assessment Program, record review, and interview with the Quality Assessment Officer (QAO), the Laboratory failed to follow the Laboratory's written policies and procedures to assess the competency of 3 of 3 testing personnel (TP) who performed gram stains and rapid plasma reagin (RPR) from 01/01/2019 to 12/31/2019. Findings Include: 1. The laboratory's Administrative Policy and Procedure Manual Competency Assessment Program (page 2) under methods for evaluating competency (points 1, 2, 3, 4, 5, and 6) states: " 1. Direct observation of routine patient test performance to include patient preparation (if applicable), specimen handling, processing and testing. 2. Monitoring the recording and reporting of test results. 3. Review of patient test results recorded in the information system /worklists, quality control records, proficiency testing results, and preventative maintenance records. 4. Direct observation of performance of instrument maintenance and function checks and/or test procedure. 5. Assessment of test performance through previously analyzed specimens, internal blind samples or external proficiency testing samples. 6. Assessment of knowledge and problem solving skills through written or verbal examination." 2. On the day of survey 09/10/2020 review of the competency assessment records during 2019 for 3 of 3 TP revealed the laboratory did not follow their Policy to evaluate points 1, 2, 3, and 6 for gram stains and RPR. 3. On 9/10/2020 at 09:45, the Quality Assessment Officer confirmed the findings above. C. Based on review of the laboratory's Administrative Policy and Procedure Manual Competency Assessment Program, record review, and interview with the Quality Assessment Officer (QAO), the Laboratory failed to follow the Laboratory's written policies and procedures to assess competency for 9 of 9 testing personnel (TP) who performed potassium hydroxide (KOH) and wet mounts from in 2018,2019, and 2020. Findings include: 1. The Administrative Policy and Procedure Manual Competency Assessment Program (page 2) under methods for evaluating competency states the six CLIA procedures for competency assessment as shown in point B. 2. On the day of the survey, 9/10/2020 review of the competency assessment records for 9 of 9 TP revealed the laboratory did not follow their policy to evaluate points 1, 2, 3, and 4 for KOH and wet mounts 3. On 09/10/202 at 10:12 a.m. the QAO confirmed the findings above. D. Based on review of competency assessment records, and interview with the Quality Assessment Officer (QAO), the Laboratory failed to asses the competency for 3 of 9 testing personnel (TP) (on the CMS-209 form listed as personnel 8, 12, and 13) who performed potassium hydroxide (KOH) and wet mounts from 01/01/2019 to 12 /31/2019. Findings include: 1. On the day of survey, 09/10/2020, the Quality Assessment Officer could not provide competency assessment records for TP 8, 12 and 13 who performed KOH and wet mount in 2019. 2. The QAO confirmed the finding above on 09/10/2020 around 10:15 am -- 2 of 3 -- D6018 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1407(e)(4)(iii) The laboratory director is responsible for the overall operation and administration of the laboratory, including the employment of personnel who are competent to perform test procedures, and record and report test results promptly, accurate, and proficiently and for assuring compliance with the applicable regulations. (e) The laboratory director must-- (e)(4)(iii) Ensure that all proficiency testing reports received are reviewed by the appropriate staff to evaluate the laboratory's performance and to identify any problems that require

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Survey - April 4, 2018

Survey Type: Standard

Survey Event ID: N9BD11

Deficiency Tags: D5791 D5791

Summary:

Summary Statement of Deficiencies D5791 ANALYTIC SYSTEMS QUALITY ASSESSMENT CFR(s): 493.1289(a)(c) (a) The laboratory must establish and follow written policies and procedures for an ongoing mechanism to monitor, assess, and when indicated, correct problems identified in the analytic systems specified in 493.1251 through 493.1283. (c) The laboratory must document all analytic systems assessment activities. This STANDARD is not met as evidenced by: Based on review of laboratory incubator temperature log, laboratory quality assessment (QA), and interview with the laboratory technical consultant (TC), the laboratory failed to identify and correct the temperature falling outside the allowable range (10/11) and illegible temperature recording (10/24) issues in 2016. Findings include: 1. The tabletop incubator temperature log (Room 163) showed a 34.9 C temperature reading (acceptable range 35-37 C) on 10/11/2016 and an unreadable temperature entry on 10/24/2016. 2. The October 2016 laboratory QA (Monthly Health Center Review) did not identify these two issues (2 of 20 temperature readings) and had no documented

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