Summary:
Summary Statement of Deficiencies D0000 A recertification survey conducted on 04/10/2023 found the MARTIN DERMATOLOGY PL clinical laboratory not in compliance with 42 CFR Part 493, Requirements for Laboratories. 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 observation, record review and interview, the laboratory failed to store the following flammable reagents according to manufacturer instructions: 100% Reagent Alcohol, Xylene Substitute XS-3 and Eosin-Y alcoholic 0.25%. Findings included: During a tour of the laboratory on 04/10/2023 at 9:45 AM, the surveyor found that the laboratory stored in an unlocked cabinet that it is not fireproof the following reagents: one gallon of 100% reagent alcohol, one gallon of XS-3 and one gallon of Eosin-Y alcoholic 0.25%. Review of the STATLAB Safety Data Sheet for those products revealed the following: -100% Reagent Alcohol to "Store locked up". - XS-3 and Eosin-Y alcoholic 0.25% to "Keep in a fireproof place". During an interview on 04/10 /2023 at 9:50 AM, the risk manager confirmed that the laboratory failed to store the reagents listed above as per manufacturer instructions. 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 --