Forefront Dermatology, S C Dba Lakeshore

CLIA Laboratory Citation Details

3
Total Citations
21
Total Deficiencyies
10
Unique D-Tags
CMS Certification Number 23D1014883
Address 6225 Prairie Street, Norton Shores, MI, 49444
City Norton Shores
State MI
Zip Code49444
Phone(231) 798-9500

Citation History (3 surveys)

Survey - May 30, 2023

Survey Type: Standard

Survey Event ID: DLX611

Deficiency Tags: D5403 D6121 D6121 D6126 D6126

Summary:

Summary Statement of Deficiencies D5403 PROCEDURE MANUAL CFR(s): 493.1251(b) The procedure manual must include the following when applicable to the test procedure: (1) Requirements for patient preparation; specimen collection, labeling, storage, preservation, transportation, processing, and referral; and criteria for specimen acceptability and rejection as described in 493.1242. (2) Microscopic examination, including the detection of inadequately prepared slides. (3) Step-by-step performance of the procedure, including test calculations and interpretation of results. (4) Preparation of slides, solutions, calibrators, controls, reagents, stains, and other materials used in testing. (5) Calibration and calibration verification procedures. (6) The reportable range for test results for the test system as established or verified in 493.1253. (7) Control procedures. (8)

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Survey - January 31, 2022

Survey Type: Standard

Survey Event ID: 297C11

Deficiency Tags: D5415 D5429 D5431 D5787 D5415 D5429 D5431 D5787

Summary:

Summary Statement of Deficiencies D5415 TEST SYSTEMS, EQUIPMENT, INSTRUMENTS, REAGENT CFR(s): 493.1252(c) Reagents, solutions, culture media, control materials, calibration materials, and other supplies, as appropriate, must be labeled to indicate the following: (1) Identity and when significant, titer, strength or concentration. (2) Storage requirements. (3) Preparation and expiration dates. (4) Other pertinent information required for proper use. This STANDARD is not met as evidenced by: . Based on observation and interview with the Clinical Manager (CM), the laboratory failed to label the Delasco 20% potassium hydroxide (KOH) reagent with the date the reagent was put into use for 2 (January 2020 to January 2022) of 2 years in possible use. Findings include: 1. During a tour of the laboratory on 1/31/2022 at 9:19 am the surveyor observed the 20% KOH reagent in use did not have an open date and the expiration date is in the future (12/31/2023). 2. When queried on 1/31/2022 at 9:31 am the CM was unable to give a date the reagent had been put into use for testing. 3. An interview on 1/31/2022 at 9:31 am, the CM confirmed there was no open date recorded on the bottle of 20% KOH in use. 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 observation and interview with the Clinical Manager (CM), the laboratory 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 -- failed to perform and document thermometer calibrations for 1 (Serial number (S/N) 181278936) of 1 thermometers in the histopathology laboratory before the expiration date. Findings include: 1. During a tour of the laboratory on 1/31/2022 at 9:19 am, the surveyor observed a ThermoScientific thermometer in use with an expiration date of 5 /15/2020 in the histopathology laboratory for the room temperature and humidity. 2. When queried on 1/31/2022 at 9:30 am, the CM was unaware the thermometer had an expiration date recorded on the back side of the thermometer and that it had expired. 2. An interview on 1/31/2022 at 9:30 am, the CM confirmed the laboratory failed to perform and document thermometer calibration for the expired thermometer or replace it. D5431 MAINTENANCE AND FUNCTION CHECKS CFR(s): 493.1254(a)(2) For unmodified manufacturer's equipment, instruments, or test systems, the laboratory must perform and document function checks as defined by the manufacturer and with at least the frequency specified by the manufacturer. Function checks must be within the manufacturer's established limits before patient testing is conducted. This STANDARD is not met as evidenced by: . Based on record review, lack of documentation, and interview with the Clinical Manager (CM), the laboratory failed to perform and document the cleaning for the mycology and parasitology microscope each day of patient testing for 183 (1/23/2020 to 1/27/2022) of 191 days of testing in 2 years. Findings include: 1. A record review of the "Microscope Maintenance and cleaning (started 10-6-15)" for the Olympus CX31 in nurse station states): a. "The microscope is to be cleaned at least one per day, when the office is seeing medical patients. i. This can be logged either in the KOH or Scabies logs if done directly after a patient. ii. Or done by the nurses and logged on the end of the day checklist. ii. This only needs to be done if the microscope is used". 2. Review of the KOH and Scabies logs revealed for 183 (1/23/2020 to 1/27/2022) of 191 days the maintenance for the microscope cleaning was not marked and the nurse end of the day checklist was either not marked, the days of the weeks not recorded on the logs. 3. An interview on 1/31/2022 at 10:49 am, the CM confirmed the methods of recording the microscope cleaning were not consistently documented and many days were missed D5787 TEST RECORDS CFR(s): 493.1283(a) The laboratory must maintain an information or record system that includes the following: (a)(1) The positive identification of the specimen. (a)(2) The date and time of specimen receipt into the laboratory. (a)(3) The condition and disposition of specimens that do not meet the laboratory's criteria for specimen acceptability. (a)(4) The records and dates of all specimen testing, including the identity of the personnel who performed the test(s). This STANDARD is not met as evidenced by: . Based on record review and interview with the Clinical Manager (CM), the laboratory failed to maintain a record system that included the specimen receipt time into the laboratory for each stage of the Mohs' tissue specimen for 3 (NS20-052, NS20-176, and NS20-231) o 14 Mohs' patient charts audited. Findings include: 1. -- 2 of 3 -- Record review for 3 of 14 Mohs' cases reviewed, the laboratory failed to include the specimen receipt time into the laboratory for each stage of the Mohs' tissue specimen recorded on the final Mohs' map as follows: a. NS20-052 - I stage b. NS20-176 - I stage c. NS20-231 - II stages 2. During the interview on 1/31/2022 at 12:07 pm, the CM confirmed the stamping in of the tissue specimens was not present on the final Mohs' maps. ***Repeat Deficiency from the 11/13/2019 survey *** -- 3 of 3 --

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Survey - November 13, 2019

Survey Type: Standard

Survey Event ID: RNI211

Deficiency Tags: D5301 D5787 D5801 D5805 D5301 D5787 D5801 D5805

Summary:

Summary Statement of Deficiencies D5301 TEST REQUEST CFR(s): 493.1241(a) The laboratory must have a written or electronic request for patient testing from an authorized person. This STANDARD is not met as evidenced by: . Based on record review and interview with the CLIA liaison, the laboratory failed to have a electronic request for patient testing for 3 (WR070464, BD012571, and KL062741 ) of 14 patient charts audited. Findings include: 1. A review of patient testing logs revealed 1 patient (WR070464) received scabies testing and 2 (BD012571 and KL062741) patients received potassium hydroxide (KOH) testing. 2. A review of the 3 patient charts revealed a lack of a test request for testing as follows: a. WR070464 - scabies testing on 2/20/18 b. BD012571 - KOH testing on 2/27/19 c. KL062741- KOH testing on 5/09/19 3. An interview on 11/13/19 at 12:08 pm with the CLIA liaison confirmed an electronic test request was not available. D5787 TEST RECORDS CFR(s): 493.1283(a) The laboratory must maintain an information or record system that includes the following: (a)(1) The positive identification of the specimen. (a)(2) The date and time of specimen receipt into the laboratory. (a)(3) The condition and disposition of specimens that do not meet the laboratory's criteria for specimen acceptability. (a)(4) The records and dates of all specimen testing, including the identity of the personnel who performed the test(s). This STANDARD is not met as evidenced by: . Based on record review and interview with the CLIA liaison, the laboratory failed to 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 -- maintain a record system that included the specimen receipt time into the laboratory for each Mohs' tissue specimen stage for 10 (NS17-001, NS18-085, NS18 -286, NS18 -421, NS18 - 629, NS18 - 879, NS19 - 052, NS19 - 190, NS19 - 516, and NS19 -805) of 10 Mohs' patient charts audited. Findings include: 1. Record review for 10 of 10 Mohs' cases reviewed, the laboratory failed to include the specimen receipt time into the laboratory for each Mohs' tissue specimen stage on the final Mohs' map as follows: a. NS17 - 001 - no time for level 1 b. NS18 - 085 - no time for level 1 c. NS18 - 286 - no time for level 1 d. NS18 - 421 -no time for levels 1 and 2 e. NS18 -629 - no time for levels 1 and 2 f. NS18 -879 - no time for level 1 g. NS19 -052 - no time for levels 1 and 2 h. NS19 -190 - no time for level 1 i. NS19 -516 - no time for levels 1-3 j. NS19-805 - no time for level 1 2. During the interview on 11/13/19 at 12: 23 pm, the CLIA Liaison acknowledged the final Mohs' map scanned into the patient's chart did not contain the specimen receipt times for each tissue stage. D5801 TEST REPORT CFR(s): 493.1291(a) The laboratory must have an adequate manual or electronic system(s) in place to ensure test results and other patient-specific data are accurately and reliably sent from the point of data entry (whether interfaced or entered manually) to final report destination, in a timely manner. This includes the following: (a)(1) Results reported from calculated data. (a)(2) Results and patient-specific data electronically reported to network or interfaced systems. (a)(3) Manually transcribed or electronically transmitted results and patient-specific information reported directly or upon receipt from outside referral laboratories, satellite or point-of-care testing locations. This STANDARD is not met as evidenced by: . Based on record review and interview with the CLIA liaison, the laboratory failed to ensure test results were reliably transferred from the patient testing log to the patients electronic medical record (EMR) for 3 (WR070464, BD012571, and KL062741) of 14 patient charts audited. Findings include: 1. A record review of the potassium hydroxide (KOH) and scabies patient testing logs revealed the following patients had testing performed on the following dates: a. Patient WR070464 - scabies testing on 2 /20/18 b. Patient BD012571 - KOH testing on 2/27/19 c. Patient KL062741 - KOH testing on 5/09/19 2. A patient chart audit of the patients tested above revealed a lack of documentation of final test reports in the patient's EMR file. 3. During the interview on 11/13/19 at 12:08 pm, the CLIA liaison acknowledged the final test reports were not documented in the patient's EMR file. D5805 TEST REPORT CFR(s): 493.1291(c) The test report must indicate the following: (c)(1) For positive patient identification, either the patient's name and identification number, or a unique patient identifier and identification number. (c)(2) The name and address of the laboratory location where the test was performed. (c)(3) The test report date. (c)(4) The test performed. (c)(5) Specimen source, when appropriate. (c)(6) The test result and, if applicable, the units of measurement or interpretation, or both. (c)(7) Any information regarding the condition and disposition of specimens that do not meet the laboratory's criteria for acceptability. -- 2 of 3 -- This STANDARD is not met as evidenced by: . Based on record review and interview with the CLIA liaison, the laboratory failed to indicate the name and address of the laboratory location where testing was performed for 12 (December 2017 to November 2019) of 12 months. Findings include: 1. Record review for 12 of 12 months of Mohs' testing revealed the Mohs' maps that was either scanned or a photographic picture taken of the report did not provide the name and address of the laboratory performing the testing. 2. During the interview on 10/13/19 at 12:23 pm, the CLIA liaison acknowledged the Mohs' reports lacked the name and address of the testing facility. -- 3 of 3 --

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