Madera County Public Health Laboratory

CLIA Laboratory Citation Details

3
Total Citations
10
Total Deficiencyies
10
Unique D-Tags
CMS Certification Number 05D0711439
Address 1604 Sunrise Ave, Madera, CA, 93638
City Madera
State CA
Zip Code93638
Phone(559) 675-7893

Citation History (3 surveys)

Survey - April 23, 2025

Survey Type: Special

Survey Event ID: VMPE11

Deficiency Tags: D2016 D6076 D0000 D2055 D6089

Summary:

Summary Statement of Deficiencies D0000 A proficiency testing desk review survey was performed on 04/23/2025, the laboratory was found not in compliance with the following CONDITION LEVEL DEFICIENCIES D2016 - 42 C.F.R. 493.803 Condition: Successful participation [proficiency testing]; and D6076 - 42 C.F.R. 493.1441 Condition: Laboratories performing high complexity testing; laboratory director. D2016 SUCCESSFUL PARTICIPATION CFR(s): 493.803(a)(b)(c) (a) Each laboratory performing nonwaived testing must successfully participate in a proficiency testing program approved by CMS, if applicable, as described in subpart I of this part for each specialty, subspecialty, and analyte or test in which the laboratory is certified under CLIA. (b) Except as specified in paragraph (c) of this section, if a laboratory fails to participate successfully in proficiency testing for a given specialty, subspecialty, analyte or test, as defined in this section, or fails to take remedial action when an individual fails gynecologic cytology, CMS imposes sanctions, as specified in subpart R of this part. (c) If a laboratory fails to perform successfully in a CMS- approved proficiency testing program, for the initial unsuccessful performance, CMS may direct the laboratory to undertake training of its personnel or to obtain technical assistance, or both, rather than imposing alternative or principle sanctions except when one or more of the following conditions exists: (1) There is immediate jeopardy to patient health and safety. (2) The laboratory fails to provide CMS or a CMS agent with satisfactory evidence that it has taken steps to correct the problem identified by the unsuccessful proficiency testing performance. (3) The laboratory has a poor compliance history. This CONDITION is not met as evidenced by: Based on review of the Certification and Survey Provider Enhanced Reporting (CASPER) - 0155D and College of American Pathologists/EXCEL (CAP) and AAB- Medcial Laboratory Evaluation (AAB) reports (for proficiency testing events: 2024-2, 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 -- 2024-3, and 2025-1), the laboratory failed to successfully participate in a proficiency testing program approved by HHS for each specialty, subspecialty and analyte or test in which the laboratory is certified under CLIA, the laboratory failed to successfully participate in the subspecialty - Parasitology, resulting in a subsequent unsuccessful performance. Refer to D2055. D2055 PARASITOLOGY CFR(s): 493.829(e) (e) Failure to achieve an overall testing event score of satisfactory performance for two consecutive testing events or two out of three consecutive testing events is unsuccessful performance. This STANDARD is not met as evidenced by: Based on desk review of Certification and Survey Provider Enhanced Reporting (CASPER) Report 0155D Individual Laboratory Profile and CAP and AAB proficiency testing evaluation reports, the laboratory failed to achieve satisfactory performances for three consecutive proficiency events in 2024 - 2025, for the subspecialty - Parasitology. The finding include: 2024 Parasitology second event, - 60%, 2024 Parasitology third event, - 60%, 2025 Parasitology first event, - 57%. A review of the 2024 and 2025 proficiency testing scores from CAP and AAB confirmed the above findings. D6076 LABORATORY DIRECTOR CFR(s): 493.1441 The laboratory must have a director who meets the qualification requirements of 493. 1443 of this subpart and provides overall management and direction in accordance with 493.1445 of this subpart. This CONDITION is not met as evidenced by: Based on a proficiency testing desk review of the Certification and Survey Provider Enhanced Reporting (CASPER) - 0155D report CAP AAB records for 2024-2, 2024- 3, and 2025-1 events, the laboratory director failed to provide overall management and a direction of the laboratory services. Refer to D6089. D6089 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1445(e)(4)(i) (e)(4)(i) The proficiency testing samples are tested as required under subpart H of this part; This STANDARD is not met as evidenced by: Based on a proficiency testing desk review of Certification and Survey Provider Enhanced Reporting (CASPER) - 0155D report; CAP and AAB records for 2024-2, 2024-3, and 2025-1 proficiency testing events, the laboratory director failed to ensure successful participation in an HHS approved proficiency testing program. Refer to D2055. -- 2 of 2 --

πŸ”’ Unlock Deficiency Summary

Get full access to the detailed deficiency summary for this facility

One-time payment β€’ Lifetime access

Survey - August 18, 2021

Survey Type: Standard

Survey Event ID: FPMD11

Deficiency Tags: D2029

Summary:

Summary Statement of Deficiencies D2029 MYCOBACTERIOLOGY CFR(s): 493.825(a) Failure to attain an overall testing event score of at least 80 percent is unsatisfactory performance. This STANDARD is not met as evidenced by: Based on observation of Mycobacterial cultures, review of 2019 proficiency testing reports from CMS (report 155, Individual Laboratory Profile) and CAP (College of American Pathologists), laboratory proficiency testing records, and patients Mycobacterial Culture test records; and interview with the Laboratory Director, it was determined that the laboratory failed to attain an overall testing event score of at least 80% in Mycobacteriology, demonstrating unsatisfactory culture and identification of mycobacteria. Findings included: 1. CMS and CAP reported the unsatisfactory score of 66% for event B- 2019, Mycobacteriology based on the unacceptable results (*) reported for 2 of 5 samples, as follows: a. Specimen # E- 07 Lab result: Neg for Mycobacteria* [No growth] CAP intended response: M. tuberculosis complex b. Specimen # E- 09 Lab result: M. tuberculosis complex * CAP intended response: Mycobac/Not MTbCom 2. The Laboratory Director affirmed (8/18/21 @ 5pm) the aforementioned unacceptable culture results and stated that the root causes were two- fold: the samples were switched during numbering (preanalytical), and that specimen #E-07 missed being plated onto additional special media (or culture conditions) so there was no growth of the organism, yielding a false negative result. 3. The reliability and quality of Mycobacterial Cultures in 2019 could not be assured. Two selected at random for this survey were as follows: Date Number Reported -------------------------------------------------------------- 12/18/19 MD19- 03020 No AFB found 12/26/19 MD19- 03062 No AFB found 4. The laboratory stated approximately 1,600 tests for mycobacteria were performed annually including cultures, Acid-Fast stains, and molecular methods. . 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 --

πŸ”’ Unlock Deficiency Summary

Get full access to the detailed deficiency summary for this facility

One-time payment β€’ Lifetime access

Survey - July 10, 2018

Survey Type: Standard

Survey Event ID: 106311

Deficiency Tags: D5449 D6053 D6022 D6127

Summary:

Summary Statement of Deficiencies D5449 CONTROL PROCEDURES CFR(s): 493.1256(d)(3)(ii)(g) Unless CMS Approves a procedure, specified in Appendix C of the State Operations Manual (CMS Pub. 7), that provides equivalent quality testing, the laboratory must-- At least once a day patient specimens are assayed or examined perform the following for-- Each qualitative procedure, include a negative and positive control material; (g) The laboratory must document all control procedures performed. This STANDARD is not met as evidenced by: Based on review and the lack of documentation of Quality Control (QC) performance for Oxidase, Catalase, and interview with the laboratory director, it was determined that the laboratory failed for each qualitative procedure, include a negative and positive control materials; the laboratory must document all control procedures performed. The findings included: a. The laboratory lack the documentation and performances at least once day patients specimens are assayed or examined perform include negative and positive control materials for Oxidase, and Catalase, tests. b. For one (1) out of one (1) random patient sampling result reviewed (3/8/2018); the laboratory analyzed and reported a Bacteriology test without performing an Oxidase, and a Catalase tests. c. The laboratory director affirmed (7/10/2018, 12:30) that the laboratory did not include negative and positive control materials for the above tests. D6022 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1407(e)(5) 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)(5) Ensure that the quality control and quality assessment programs 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 -- are established and maintained to identify failures in quality as they occur. This STANDARD is not met as evidenced by: Based on review and the lack of documentation of the laboratory's quality control (QC) performance, and the competency evaluation for all testing personnel, it was determined that the laboratory director/technical consultant/and or technical supervisor failed to ensure the quality control and quality assessment programs are established and maintained to identify failures in quality as they occur. See D5449, D6053, and D6127. D6053 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(9) The technical consultant is responsible for evaluating and documenting the performance of individuals responsible for moderate complexity testing at least semiannually during the first year the individual tests patient specimens. This STANDARD is not met as evidenced by: Based on request, review and the lack of documentation for competency assessments, and interview with laboratory director, for nine (9) out of nine (9) random patient sampling test results reviewed covering period from 6/16/2016 to 5/25/2018, it was determined that the laboratory technical consultant/laboratory director failed to perform and document the performance of individuals responsible for moderate complexity testing. The findings included: a. There was no documentation to show that the testing personnel were evaluated during the first six months and annually thereafter. The evaluations must include but are not limited to the following: Direct observations of the testing performed (including sample handling, processing and testing) Monitoring the recording and reporting of results Direct observation of instrument maintenance Review of intermediate worksheets, quality control records. Assessment of testing previously analyzed specimens (external QC and proficiently testing) Assessment of problem solving skills b. There are two (2) testing personnel (TP) listed on the CMS 209 and LAB 116 forms, no documentation of competency and evaluation for the years 2016, 2017, and 2018. c. The laboratory director affirmed (7/10/2018, 12:30) that no competency assessments were performed and documented by the laboratory director and or technical consultant. D6127 TECHNICAL SUPERVISOR RESPONSIBILITIES CFR(s): 493.1451(b)(9) The technical supervisor is responsible for evaluating and documenting the performance of individuals responsible for high complexity testing at least semiannually during the first year the individual tests patient specimens. This STANDARD is not met as evidenced by: Based on request, review and the lack of documentation for competency assessments, and interview with laboratory director, for nine (9) out of nine (9) random patient sampling test results reviewed covering period from 6/16/2016 to 5/25/2018, it was determined that the laboratory technical supervisor/laboratory director failed to perform and document the performance of individuals responsible for high complexity testing. The findings included: a. There was no documentation to show that the testing -- 2 of 3 -- personnel were evaluated during the first six months and annually thereafter. The evaluations must include but are not limited to the following: Direct observations of the testing performed (including sample handling, processing and testing) Monitoring the recording and reporting of results Direct observation of instrument maintenance Review of intermediate worksheets, quality control records. Assessment of testing previously analyzed specimens (external QC and proficiently testing) Assessment of problem solving skills b. There are two (2) testing personnel (TP) listed on the CMS 209 and LAB 116 forms, no documentation of competency and evaluation for the years 2016, 2017, and 2018. c. The laboratory director affirmed (7/10/2018, 12:30) that no competency assessments were performed and documented by the laboratory director and or technical supervisor. -- 3 of 3 --

πŸ”’ Unlock Deficiency Summary

Get full access to the detailed deficiency summary for this facility

One-time payment β€’ Lifetime access