Laboratorio Clinico Bio Tech Ii

Summary Statement of 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 Proficiency Testing program records review (year 2023) and laboratory director interview on May 7, 2024 at 9:14 AM; it was determined that the laboratory failed to attestated that the proficiency samples were tested in the same manner that they tested the laboratory patient samples. The findings include: 1. On May 7, 2024 at 9: 00 AM, the proficiency testing program record was reviewed. The proficiency attestation statement year 2023 were requested. The laboratory director did not provide any attestation statement of the year 2023. 2. The laboratory director stated, on May 7, 2024 at 9:14 AM, that they no print nor signed the attestation statement of the proficiency program for the year 2023. D6016 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1407(e)(4)(i) The laboratory director is responsible for the overall operation and administration of the laboratory, including the employment of personnel who are competent to perform test procedures, and record and report test results promptly, accurate, and proficiently and for assuring compliance with the applicable regulations. (e) The laboratory director must-- (e)(4)(i) Ensure that the proficiency testing samples are tested as required under Subpart H of this part; 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 -- This STANDARD is not met as evidenced by: Based on the review of the profiency program record and interview with the laboratory director on May 7, 2024 at 9:14 AM, it was determined that the laboratory director fail to meet the required requirements under subpart H. Refer to D2009. D6018 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1407(e)(4)(iii) The laboratory director is responsible for the overall operation and administration of the laboratory, including the employment of personnel who are competent to perform test procedures, and record and report test results promptly, accurate, and proficiently and for assuring compliance with the applicable regulations. (e) The laboratory director must-- (e)(4)(iii) Ensure that all proficiency testing reports received are reviewed by the appropriate staff to evaluate the laboratory's performance and to identify any problems that require

Summary Statement of Deficiencies D5405 PROCEDURE MANUAL CFR(s): 493.1251(c) Manufacturer's test system instructions or operator manuals may be used, when applicable, to meet the requirements of paragraphs (b)(1) through (b)(12) of this section. Any of the items under paragraphs (b)(1) through (b)(12) of this section not provided by the manufacturer must be provided by the laboratory. This STANDARD is not met as evidenced by: Based on manufacturer's instructions, rapid plasma regain (RPR) test quality control records and laboratory director interview on June 15, 2018 at 11:00 AM, it was determined that the laboratory failed to follow manufacturer's instructions when 56 out of 56 patients specimens were tested and reported for RPR by Immnuno Detector RPR method from January 11, 2018 to June 14, 2018. The findings include: 1. The Immnuno Detector RPR manufacturer instructed the laboratory to perform the RPR tests at room temperature range from 23 to 29 C. 2. On June 15, 2018 at 11:00 AM, the RPR test quality control records showed that the laboratory tested and reported 56 out of 56 patients for RPR tests at temperatures below the manufacturer required from January 11, 2018 to June 14, 2018: Date temperature (C) January 11, 2018 22 January 16, 2018 22 January 22, 2018 21 January 24, 2018 22 January 30, 2018 22 February, 1, 2018 21 February, 5, 2018 22 February, 7, 2018 22 February, 8 2018 22 February, 12, 2018 22 February, 14, 2018 21 February, 15, 2018 22 February, 26, 2018 22 March 3, 2018 21 March 10, 2018 22 March 14, 2018 21 March 17, 2018 22 March 19, 2018 21 March 22, 2018 22 April 2, 2018 21 April 3, 2018 22 April 13, 2018 22 April 25, 2018 22 April 26, 2018 22 May 1, 2018 22 May 7, 2018 22 May 15, 2018 22 May 23, 2018 22 May 24, 2018 22 May 28, 2018 22 May 29, 2018 22 June 4, 2018 22 June 6, 2018 22 June 13, 2018 22 June 14, 2018 22 3. The laboratory director 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 -- confirmed on June 15, 2018 at 11:10 AM, that the laboratory tested and reported 56 out of 56 patients for RPR tests at temperatures below the manufacturer required from January 11, 2018 to June 14, 2018. D6019 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1407(e)(4)(iv) The laboratory director is responsible for the overall operation and administration of the laboratory, including the employment of personnel who are competent to perform test procedures, and record and report test results promptly, accurate, and proficiently and for assuring compliance with the applicable regulations. (e) The laboratory director must-- (e)(4)(iv) Ensure that an approved