Family Medical Center

CLIA Laboratory Citation Details

1
Total Citation
4
Total Deficiencyies
4
Unique D-Tags
CMS Certification Number 25D0710758
Address 1024 Martin Luther King Drive, Marks, MS, 38646
City Marks
State MS
Zip Code38646
Phone662 326-3502
Lab DirectorRICHARD WALLER

Citation History (1 survey)

Survey - July 25, 2018

Survey Type: Standard

Survey Event ID: 8K4111

Deficiency Tags: D5437 D6019 D6021 D6049

Summary:

Summary Statement of Deficiencies D5437 CALIBRATION AND CALIBRATION VERIFICATION CFR(s): 493.1255(a) Unless otherwise specified in this subpart, for each applicable test system the laboratory must perform and document calibration procedures-- (1) Following the manufacturer's test system instructions, using calibration materials provided or specified, and with at least the frequency recommended by the manufacturer; (2) Using the criteria verified or established by the laboratory as specified in 493.1253(b) (3)-- (2)(i) Using calibration materials appropriate for the test system and, if possible, traceable to a reference method or reference material of known value; and (2)(ii) Including the number, type, and concentration of calibration materials, as well as acceptable limits for and the frequency of calibration; and (3) Whenever calibration verification fails to meet the laboratory's acceptable limits for calibration verification. This STANDARD is not met as evidenced by: Based on Cell Dyn Emerald calibration documentation and interview with testing personnel at 3:00 pm on the day of survey, 7/25/18, the laboratory failed to perform the required calibration on the Cell Dyn Emerald hematology analyzer at least once every 6 months as required by the manufacturer. Since the last survey on 7/19/16, calibration was documented as performed on 1/9/17 and 1/29/18. This time frame exceeds the 6 month requirement. D6019 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1407(e)(4)(iv) 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)(iv) Ensure that an approved

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