Murfreesboro Medical Clinic

CLIA Laboratory Citation Details

1
Total Citation
2
Total Deficiencyies
2
Unique D-Tags
CMS Certification Number 44D2169046
Address 3626 Shelbyville Pike-Main Lab Floor 1, Murfreesboro, TN, 37127
City Murfreesboro
State TN
Zip Code37127
Phone615 439-2226
Lab DirectorRICHARD MICHAELSON

Citation History (1 survey)

Survey - February 12, 2024

Survey Type: Standard

Survey Event ID: WZLR11

Deficiency Tags: D5211 D5403

Summary:

Summary Statement of Deficiencies D5211 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(a) The laboratory must review and evaluate the results obtained on proficiency testing performed as specified in subpart H of this part. This STANDARD is not met as evidenced by: Based on review of the College of American Pathologists (CAP) Hematology evaluation report for 2023 FH 13-C and staff interview, the laboratory failed to evaluate 7 of 10 unacceptable or ungraded Blood Cell ID results and 10 of 10 nRBC results in 2023. The findings include: 1. Review of the CAP Hematology evaluation report for 2023 FH 13-C revealed the following sample numbers scored as unacceptable: BCP-23, BCP-25, and the following sample numbers noted as ungraded: FH 13-11, FH 13-12, FH 13-13, FH 13-14, FH 13-15 for nRBC/100 WBC and nRBC Absolute, and BCP-26, BCP-27, BCP-28, BCP-29, and BCP-30 for Blood Cell ID. The evaluation report was signed by the technical consultant with no documentation of

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