M & M Pediatrics Pllc

CLIA Laboratory Citation Details

2
Total Citations
5
Total Deficiencyies
3
Unique D-Tags
CMS Certification Number 45D1033622
Address 3354 International Blvd, Brownsville, TX, 78521
City Brownsville
State TX
Zip Code78521
Phone956 548-6666
Lab DirectorHUMBERTO MD

Citation History (2 surveys)

Survey - July 13, 2022

Survey Type: Standard

Survey Event ID: HH6711

Deficiency Tags: D3031

Summary:

Summary Statement of Deficiencies D3031 RETENTION REQUIREMENTS CFR(s): 493.1105(a)(3) Analytic systems records. Retain quality control and patient test records (including instrument printouts, if applicable) and records documenting all analytic systems activities specified in 493.1252 through 493.1289 for at least 2 years. This STANDARD is not met as evidenced by: Based on review of the laboratory's quality control records, patient records, and confirmed in interview of laboratory personnel, the laboratory failed to retain patient and quality control records for Rotavirus from June 2, 2021 to October 31, 2021. The findings included: 1. Review of the laboratory's Rotavirus quality control records from June 2, 2021 to June 30, 2022 found no records could be recovered to ensure the laboratory performed quality control according to its IQCP from June 2, 2021 to October 31, 2021. a. The laboratory failed to retain Rotavirus quality control records from June 2, 2021 to October 31, 2021 for a minimum of two years. 2. Review of the laboratory's patient test records from June 2, 2021 to June 30, 2022 found no records could be recovered from June 2, 2021 to October 31, 2021. The laboratory failed to retain patient test records for a minimum of two years. 3. The laboratory was asked to provide documentation of retaining patient and quality control records for a minimum of two years. No documentation was provided. 4. The findings were confirmed in interview with the technical consultant on July 13, 2022 at 11:00 hours in the break room. Key: IQCP - Individualized Quality Control Plan 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 - June 10, 2021

Survey Type: Standard

Survey Event ID: JEDI11

Deficiency Tags: D0000 D1001 D0000 D1001

Summary:

Summary Statement of Deficiencies D0000 Noted deficiencies and plans of correction were discussed with the laboratory representatives at the entrance and exit conferences. The facility representatives were given an opportunity to provide evidence of compliance with the noted deficiency, and no such evidence was provided prior to survey exit. The facility was found to be in compliance with applicable Conditions of Participation in the CLIA program, and certification is recommended. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the

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