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 laboratory observations, a review of the laboratory policy, and staff interviews, the laboratory failed to follow safety procedures when the laboratory space and the office kitchen were in the same location. The findings include: 1. Observation of the laboratory on 06/10/2024 at 10:00 am revealed equipment and reagents in use for processing patient tissue removed during Mohs surgical procedures. Also observed was a kitchen area separated form the laboratory by a curtain divider. 2. A review of the laboratory policy titled "OSHA Outpatient Healthcare Policies & Procedures" in the section "General Policies" revealed that "Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are strictly prohibited in treatment areas, sterilization areas, and laboratory areas or waste storage areas." 3. An interview with the laboratory director on 06/10/2024 at 12:00 pm confirmed the findings. Word Key OSHA-Occupational Safety and Health Administration 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 --