Mary M Hanna Md

CLIA Laboratory Citation Details

2
Total Citations
6
Total Deficiencyies
2
Unique D-Tags
CMS Certification Number 33D0135499
Address 1812 Richmond Avenue, Staten Island, NY, 10314
City Staten Island
State NY
Zip Code10314
Phone(718) 761-0124

Citation History (2 surveys)

Survey - May 1, 2019

Survey Type: Special

Survey Event ID: 1AKX11

Deficiency Tags: D2000 D6015 D2000 D6015

Summary:

Summary Statement of Deficiencies D2000 ENROLLMENT AND TESTING OF SAMPLES CFR(s): 493.801 Each laboratory must enroll in a proficiency testing (PT) program that meets the criteria in subpart I of this part and is approved by HHS. The laboratory must enroll in an approved program or programs for each of the specialties and subspecialties for which it seeks certification. The laboratory must test the samples in the same manner as patients' specimens. For laboratories subject to 42 CFR part 493 published on March 14, 1990 (55 FR 9538) prior to September 1, 1992, the rules of this subpart are effective on September 1, 1992. For all other laboratories, the rules of this subpart are effective January 1, 1994. This CONDITION is not met as evidenced by: Based on a Proficiency Testing (PT) desk review of Center for Medicaid and Medicare Services (CMS) PT records, the laboratory failed to enroll in an approved PT program for the subspecialty Bacteriology/throat cultures for the calendar year 2019. THIS IS A RECITED DEFICIENCY FROM THE PT DESK REVIEWS CONDUCTED ON AUGUST 24, 2018 AND NOVEMBER 17, 2016. D6015 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1407(e)(4) 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) Ensure that the laboratory is enrolled in an HHS approved proficiency testing program for the testing performed. 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 a PT desk review of CMS PT records, the laboratory director failed to ensure that the laboratory is enrolled in an approved PT program for the subspecialty Bacteriology/throat cultures for the calendar year 2019. Refer to D2000. -- 2 of 2 --

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Survey - August 14, 2018

Survey Type: Special

Survey Event ID: LR5Y11

Deficiency Tags: D2000 D2000

Summary:

Summary Statement of Deficiencies D2000 ENROLLMENT AND TESTING OF SAMPLES CFR(s): 493.801 Each laboratory must enroll in a proficiency testing (PT) program that meets the criteria in subpart I of this part and is approved by HHS. The laboratory must enroll in an approved program or programs for each of the specialties and subspecialties for which it seeks certification. The laboratory must test the samples in the same manner as patients' specimens. For laboratories subject to 42 CFR part 493 published on March 14, 1990 (55 FR 9538) prior to September 1, 1992, the rules of this subpart are effective on September 1, 1992. For all other laboratories, the rules of this subpart are effective January 1, 1994. This CONDITION is not met as evidenced by: Based on a Proficiency Testing (PT) desk review of Center for Medicaid and Medicare Services (CMS) PT records and confirmed in a phone call with the laboratory director, the laboratory failed to enroll in approved PT program for the specialty Bacteriology/throat cultures for the calendar year 2018. 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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