Fl Hospital Physician Group Inc Dba

CLIA Laboratory Citation Details

2
Total Citations
4
Total Deficiencyies
3
Unique D-Tags
CMS Certification Number 10D0289752
Address 403 E Dr Martin Luther King Jr Blvd, Tampa, FL, 33603
City Tampa
State FL
Zip Code33603
Phone(813) 224-9025

Citation History (2 surveys)

Survey - March 31, 2023

Survey Type: Standard

Survey Event ID: 1WFA11

Deficiency Tags: D0000 D5429

Summary:

Summary Statement of Deficiencies D0000 An announced CLIA recertification survey was conducted at Mahesh Patel MD PA on 03/31/2023. The laboratory is not in compliance with 42 CFR Part 493, Requirements for Laboratories. The following is a description of the standard level deficiencies: D5429 MAINTENANCE AND FUNCTION CHECKS CFR(s): 493.1254(a)(1) For unmodified manufacturer's equipment, instruments, or test systems, the laboratory must perform and document maintenance as defined by the manufacturer and with at least the frequency specified by the manufacturer. This STANDARD is not met as evidenced by: Based on interview with the Technical Consultant and record review of the manufacturer's instructions for use and maintenance logs, the laboratory failed to document weekly instrument maintenance for the Beckman Coulter Access 2 analyzer for testing prostate specific antigen, free prostrate specific antigen, and testosterone for 85 weeks out of 104 weeks for two out of two years (2021-2023) reviewed. Findings included: Review of the Beckman Coulter Access 2 Instructions for Use revealed "If the system is not used to run assays every day, it is still important to perform weekly maintenance on schedule to ensure that the system is ready when needed." Review of the Access 2 instructions for use maintenance log revealed weekly maintenance required: Cleaning the instrument exterior Inspecting the liquid waste bottle Checking waste filter bottle Inspecting/cleaning the primary probe Replacing/cleaning aspirate probes Running the daily maintenance Running the system check Review of the "Access 2 Maintenance Log" logs revealed that weekly maintenance had not been documented for the followings weeks: 1. 4th week of March 2021 2. 1st week of May 2021 3. 2nd week of May 2021 4. 3rd week of May 2021 5. 4th week of May 2021 6. 1st week of June 2021 7. 2nd week of June 2021 8. 3rd week of June 2021 9. 4th week of June 2021 10. 2nd week of July 2021 11. 3rd week of July 2021 12. 1st week of August 2021 13. 2nd week of August 2021 14. 3rd 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 -- week of August 2021 15. 1st week of September 2021 16. 2nd week of September 2021 17. 3rd week of September 2021 18. 4th week of September 2021 19. 1st week of October 2021 20. 3rd week of October 2021 21. 4th week of October 2021 22. 1st week of November 2021 23. 2nd week of November 2021 24. 3rd week of November 2021 25. 4th week of November 2021 26. 1st week of December 2021 27. 2nd week of December 2021 28. 3rd week of December 2021 29. 4th week of December 2021 30. 1st week of January 2022 31. 2nd week of January 2022 32. 3rd week of January 2022 33. 4th week of January 2022 34. 1st week of February 2022 35 2nd week of February 2022 36. 3rd week of February 2022 37. 4th week of February 2022 38. 1st week of March 2022 39. 2nd week of March 2022 40. 3rd week of March 2022 41. 4th week of March 2022 42. 1st week of April 2022 43. 2nd week of April 2022 44. 3rd week of April 2022 45. 4th week of April 2022 46. 1st week of May 2022 47. 2nd week of May 2022 48. 3rd week of May 2022 49. 4th week of May 2022 50 1st week of June 2022 51. 2nd week of June 2022 52. 3rd week of June 2022 53. 4th week of June 2022 54. 1st week of July 2022 55. 2nd week of July 2022 56. 4th week of July 2022 57. 1st week of August 2022 58. 2nd week of August 2022 59. 3rd week of August 2022 60. 4th week of August 2022 61. 2nd week of September 2022 62. 3rd week of September 2022 63. 4th. week of September 2022 64. 1st week of October 2022 65. 2nd week of October 2022 66. 3rd week of October 2022 67. 4th week of October 2022 68. 1st week of November 2022 69 2nd week of November 2022 70. 3rd week of November 2022 71. 4th week of November 2022 72. 2nd week of December 2022 73. 3rd week of December 2022 74. 4th week of December 2022 75. 1st week of January 2023 76. 2nd week of January 2023 77. 3rd week of January 2023 78. 1st week of February 2023 79. 2nd week of February 2023 80. 3rd week of February 2023 81. 4th week of February 2023 82. 1st week of March 2023 83. 2nd week of March 2023 84. 3rd week of March 2023 85. 4th week of March 2023 Interview with the Technical Consultant on 3/31/23 at 1:16 PM confirmed the weekly maintenance was not performed every week. -- 2 of 2 --

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Survey - October 15, 2020

Survey Type: Standard

Survey Event ID: PUJN11

Deficiency Tags: D2009 D0000

Summary:

Summary Statement of Deficiencies D0000 An announced CLIA recertification survey was conducted at Mahesh Patel MD PA on 10/15/20. The laboratory is not in compliance with 42 CFR Part 493, Requirements for Laboratories. The following is a description of the standard level 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 and interview with Testing Person #B, the laboratory failed to have a signed attestation statement for 1 (3rd testing event in 2019) out of 8 (2nd, and 3rd testing events in 2018, 1st, 2nd, and 3rd testing events in 2019, and 1st, 2nd, and 3rd testing events in 2020) testing events reviewed. Findings Included: Review of API proficiency testing revealed the attestation statement for Chemistry Core in the 3rd testing event in 2019 had not been signed by the laboratory director or the testing personnel. Interview on 10 /15/20 at 11:00 AM with Testing Person #B confirmed that the API Chemistry Core 3rd testing event in 2019 attestation sheet had not been signed. 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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