Pediatric Clinic Of Cabot, The

Summary Statement of Deficiencies D5311 SPECIMEN SUBMISSION, HANDLING, AND REFERRAL CFR(s): 493.1242(a) The laboratory must establish and follow written policies and procedures for each of the following, if applicable: (1) Patient preparation. (2) Specimen collection. (3) Specimen labeling, including patient name or unique patient identifier and, when appropriate, specimen source. (4) Specimen storage and preservation. (5) Conditions for specimen transportation. (6) Specimen processing. (7) Specimen acceptability and rejection. (8) Specimen referral. This STANDARD is not met as evidenced by: Through review of laboratory policy and procedure, observation and interview it was determined that the laboratory failed to label one of one specimen collection containers with patient name or unique patient identifier. Findings follow: A) During a tour of the laboratory on 1/29/21 at approximately 11:45 AM one urine specimen was observed in a sink in the testing area labeled with the patient's first and last name only. B) Review of the laboratory policy and procedure revealed that specimen containers are to be labeled with the patient's first and last names and a unique patient identifier, patient number or patient's date of birth. C) In an interview on 1/29/21 at approximately 12:00 , the laboratory staff member, identified as number two on the CMS 209 form, confirmed that the specimen identified above lacked proper patient identification on the container as required by policy and procedure. 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 --

Summary Statement of Deficiencies D5805 TEST REPORT CFR(s): 493.1291(c) The test report must indicate the following: (c)(1) For positive patient identification, either the patient's name and identification number, or a unique patient identifier and identification number. (c)(2) The name and address of the laboratory location where the test was performed. (c)(3) The test report date. (c)(4) The test performed. (c)(5) Specimen source, when appropriate. (c)(6) The test result and, if applicable, the units of measurement or interpretation, or both. (c)(7) Any information regarding the condition and disposition of specimens that do not meet the laboratory's criteria for acceptability. This STANDARD is not met as evidenced by: Through a review of 10 randomly selected medical records and interviews with laboratory staff, it was determined the laboratory test report failed to include the name and address of Pediatric Clinic of Cabot (the laboratory where testing was performed). Survey findings include: A. Two of ten CBC (complete blood count) reports from randomly selected medical records failed to include the name and address of the laboratory location where the test was performed. Patient #9157 with reported CBC results on 6/4/2018 and patient #71209 with reported CBC results on 4/23/2018 listed named lab which is in another state instead of the onsite lab, which performed testing. B. In an interview, at 11:28 on 7/20/2018, the technical consultant (as listed on the form CMS-209) confirmed the CBC results sent via interface from the Medonic hematology analyzer to the electronic medical record failed to include the name and address of the performing laboratory but included another facility (laboratory #2) which did not perform the CBC. 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 --