Golden State Dermatology - Merced

CLIA Laboratory Citation Details

3
Total Citations
5
Total Deficiencyies
5
Unique D-Tags
CMS Certification Number 05D0933383
Address 388 E Yosemite Ave Ste 100, Merced, CA, 95340
City Merced
State CA
Zip Code95340
Phone(209) 722-7801

Citation History (3 surveys)

Survey - November 20, 2024

Survey Type: Standard

Survey Event ID: JKMO11

Deficiency Tags: D3011 D6084 D5435

Summary:

Summary Statement of Deficiencies D3011 FACILITIES CFR(s): 493.1101(d) Safety procedures must be established, accessible, and observed to ensure protection from physical, chemical, biochemical, and electrical hazards, and biohazardous materials. This STANDARD is not met as evidenced by: Based on the surveyor's observation during the laboratory tour, review of policies and procedures, preventive maintenance (PM) records, and interview with the office manager (OM), it was determined that the laboratory failed to follow and document the established safety procedures to ensure protection from physical, chemical, biochemical, and biohazardous materials. The findings include: 1. Based on the surveyor's observations during the laboratory tour on November 20, 2024, no eye wash station or portable eye wash bottles were found. 2. Based on the review of the PM records, no documentation could be retrieved for the eye wash bottle at the time of the survey. 3. The OM affirmed by interview on November 20, 2024, at approximately 12:50 p.m. that the laboratory lacked an eye wash log for the years 2022, 2023, and 2024 and failed to find the physical bottle near the processing and testing areas. 4. Based on the laboratory's annual testing volume declaration submitted at the time of the survey, the laboratory processed and reported approximately 3,202 patient test samples for Dermatopathology. D5435 MAINTENANCE AND FUNCTION CHECKS CFR(s): 493.1254(b)(2) For equipment, instruments, or test systems developed in-house, commercially available and modified by the laboratory, or maintenance and function check protocols are not provided by the manufacturer, the laboratory must: (i) Define a function check protocol that ensures equipment, instrument, and test system 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 -- performance that is necessary for accurate and reliable test results and test result reporting. (ii) Perform and document the function checks, including background or baseline checks, specified in paragraph (b)(2)(i) of this section. Function checks must be within the laboratory's established limits before patient testing is conducted. This STANDARD is not met as evidenced by: Based on a review of the laboratory's policies and procedures, equipment function check documentation, preventive maintenance (PM) log sheets, five (5) randomly selected Mohs patient test records, and an interview with the office manager (OM), it was determined that the laboratory failed to ensure function checks and PM performed were documented. The findings include: 1. Based on the survey on November 20, 2024, at approximately 12:00 p.m., no documentation could be retrieved for the stain preventive maintenance (PM) for four (4) out of 5 Mohs patient test records reviewed for the years 2022 and 2023. 2. Based on the review of PM records, no documentation could be retrieved to support the OM ' s claim that the eye wash bottle was checked for the years 2022, 2023, and 2024. 3. The OM stated in an interview at approximately 12:00 p.m. on November 20, 2024, that the laboratory had separate binders for Mohs on each year but could not locate it at the time of the survey as mentioned in statement #1. Also, the OM affirmed in the same interview that the laboratory lacked an eye wash PM record to document every check as cited in statement #2. 4. Based on the laboratory's annual testing declaration submitted at the time of the survey, the laboratory performed and reported approximately 3,202 patient tests for Dermatopathology. D6084 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1445(e)(2) The laboratory director must ensure that the physical plant and environmental conditions provide a safe environment in which employees are protected from physical, chemical, and biological hazards. This STANDARD is not met as evidenced by: Based on the surveyor's findings, the laboratory director is herein cited for the deficient practice in failure to provide and overall administration of the laboratory to ensure a safe environment in which personnel are protected from physical, chemical, biochemical, and biohazardous materials. Findings include: See D3011 and D5435. -- 2 of 2 --

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Survey - March 3, 2020

Survey Type: Standard

Survey Event ID: D9E011

Deficiency Tags: D5203

Summary:

Summary Statement of Deficiencies D5203 SPECIMEN IDENTIFICATION AND INTEGRITY CFR(s): 493.1232 The laboratory must establish and follow written policies and procedures that ensure positive identification and optimum integrity of a patient's specimen from the time of collection or receipt of the specimen through completion of testing and reporting of results. This STANDARD is not met as evidenced by: Based on review of patient histopathology and Mohs surgical procedures slides, patient final testing reports (medical records), slide labeling and interview with the laboratory personnel, it was determined that from 01/30/2018 through 02/18/2020 for one (1) out of twelve (12) random patients' testing records reviewed, the laboratory failed to follow written policies and procedures for specimen collection, labeling and Mohs surgery reports for each biopsy specimen. The findings included: a. Review of five (5) Mohs patient slides, specimen ID 19-009 (Rt Post Ear) 12/13/2019, the slide unique identifier 19-009 found on the Mohs surgical slides did not match the unique identifier (Mohs Case number 19-069) found on the final patient's testing report. b. On 03/03/2020 16:30 (survey date), the laboratory personnel confirmed that the unique slide identifier(ID 19-009) found on the (5) Mohs slides did not match the unique slide identifier (Mohs Case number 19-069) reported in the patient's final testing report. c. Based on the laboratory's annual test volume declaration (02/25/2020) the laboratory performed 3,800 histopathology and (Mohs) tests annually. 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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Survey - January 10, 2018

Survey Type: Standard

Survey Event ID: F73T11

Deficiency Tags: D5801

Summary:

Summary Statement of Deficiencies 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 review for one (1) of ten (10) patients' histopathology slides from 01/05 /2017 to 01/13/2018, patients medical records, and an interview with a laboratory personnel, it was determined that the laboratory failed to ensure that a histopathology final report result was accurately entered onto the patient's final report (medical record). 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. The findings included: a. Review on 01/10/2018 (survey date 12:00) of the laboratory's test records, slide identifiers and final test report (medical report) for the patient's histopathology slide ID UII-776, (T,S) Right Axilla B (10/03/2017), it was determined that the electronic patient's final report was missing from the patient's medical record. b. On 01/10/2018 the laboratory personnel affirmed that the patient's medical record final report result could not be retrieved in the MR. c. The laboratory testing declaration (01/07/2018) estimated a total annual of 3,200 histopathology testing performed and reported. 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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