Summary:
Summary Statement of Deficiencies D0000 An announced CLIA recertification survey was conducted at Florida Healthcare Associates PL on March 10, 2026. The laboratory was surveyed under 42 CFR Part 493, Requirement for Laboratories. The following is a description of the standard level deficiency: D5311 SPECIMEN SUBMISSION, HANDLING, AND REFERRAL CFR(s): 493.1242(a) (a) The laboratory must establish and follow written policies and procedures for each of the following, if applicable: (a)(1) Patient preparation. (a)(2) Specimen collection. (a)(3) Specimen labeling, including patient name or unique patient identifier and, when appropriate, specimen source. (a)(4) Specimen storage and preservation. (a)(5) Conditions for specimen transportation. (a)(6) Specimen processing. (a)(7) Specimen acceptability and rejection. (a)(8) Specimen referral. This STANDARD is not met as evidenced by: Based on record review and interview, the laboratory failed to have a policy on specimen collection date and time on patient test reports, and failed to document the correct specimen collection times for 4 out of 4 patient reports, (1, 2, 3, 4) reviewed. Findings Include: 1. Review of the CLINICAL LABORATORY IMPROVEMENT AMENDMENTS OF 1988 (CLIA) APPLICATION FOR CERTIFICATION revealed, the hours of laboratory testing are from 9:00 AM to 5:00 PM, Monday through Friday. 2. Review of Culminative Reports revealed the following: 1. Patient 1 was collected at 2/28/2025 at 12:00 AM, and tested on 2/28/2025 at 10:29 AM, for Complete Blood Count (CBC) testing. 2. Patient 2 was collected on 1/17/2026 at 12: 00 AM, and tested on 1/17/2026 at 12:13 PM, for CBC. 3. Patient 3 was collected on 9 /11/2025 at 12:00 AM, and tested on 9/11/2025 at 4:13 PM, for CBC. 4. Patient 4 was collected on 8/27/2024 at 12:00 AM, and tested on 8/27/2024 at 11:12 AM, for CBC. 3. Review of patient requisitions revealed the following: 1. Patient 1 had a requisition for check-in time for CBC collection on 2/28/2025 at 7:35 AM. 2. Patient 2 had a 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 -- requisition for a check-in time for CBC collection on 1/17/2026 at 10:00 AM. 3. Patient 3 had a requisition for check-in time for CBC collection on 9/11/2025 at 8:00 AM. 4. Patient 4 had a requisition for check-in time for CBC collection on 8/27/2024 at 8:21 AM. 4. Review of the specimen policy read, "All spc collect must bear the following: 1.Pt full name + 2 ID 2. Date drawn 3. Phlebotomist initials." [as I see it] 5. Review of the Test reporting policy revealed there was no policy for how specimen collection dates and time should be labeled on the final report. 6. On 3/10/2026 at 3: 30 PM, Testing Personnel A and Testing Personnel B confirmed they could not change collection times on the final reports. Word Key spc - specimen Pt - patient ID - identification -- 2 of 2 --