Piedmont Cosmetic Surgery & Dermatology Center, Pa

CLIA Laboratory Citation Details

3
Total Citations
36
Total Deficiencyies
14
Unique D-Tags
CMS Certification Number 34D0916100
Address 765 Highland Oaks Drive, Suite 100, Winston-Salem, NC, 27103
City Winston-Salem
State NC
Zip Code27103
Phone(336) 760-4004

Citation History (3 surveys)

Survey - March 12, 2024

Survey Type: Standard

Survey Event ID: FQLV11

Deficiency Tags: D3037 D5211 D5217 D5403 D5477 D5819 D6091 D6094 D6127 D6127 D3037 D5211 D5217 D5403 D5477 D5785 D5785 D5819 D6091 D6094

Summary:

Summary Statement of Deficiencies D3037 RETENTION REQUIREMENTS CFR(s): 493.1105(a)(4) Proficiency testing records. Retain all proficiency testing records for at least 2 years. This STANDARD is not met as evidenced by: Based on review of WSLH (Wisconsin State Laboratory of Hygiene) proficiency testing records and interview with the histotechnician 3/12/24, the laboratory failed to retain all proficiency testing records for at least two years from the date of the proficiency testing event. Findings: 1. Review of WSLH proficiency testing records revealed the laboratory failed to retain the graded results for the following test events: a. 2021 B3 test event b. 2023 B1 and B2 test events. 2. Review of WSLH proficiency testing records revealed the laboratory failed to retain attestation statements signed by the laboratory director as testing personnel for the following test events: a. 2021 B1, B2, and B3 test events b. 2022 B1, B2, and B3 test events c. 2023 B1, B2, and B3 test events. During interview at approximately 11:20 a.m., the histotechnician stated they were unaware the laboratory director needed to sign the attestation statements as both laboratory director and testing personnel. 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 2021, 2022, and 2023 WSLH proficiency testing records and interview with the histotechnician 3/12/24, the laboratory failed to evaluate ungraded Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 6 -- and unacceptable results on 4 of 9 proficiency testing events reviewed. Findings: The laboratory failed to evaluate ungraded and unacceptable proficiency testing results on the following events: 1. 2022 B2 test event - no evaluation of ungraded result for sample DM-7. 2. 2022 B3 test event - no evaluation of ungraded result for sample DM-11 and unacceptable result for sample DM-15. 3. 2023 B2 test event - no evaluation of ungraded results for samples DM-6, DM-7, and DM-10. 4. 2023 B3 test event - no evaluation of ungraded result for sample DM-11. During interview at approximately 11:20 a.m., the histotechnician confirmed that the laboratory had not evaluated ungraded and unacceptable results. D5217 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(c)(1) At least twice annually, the laboratory must verify the accuracy of any test or procedure it performs that is not included in subpart I of this part. This STANDARD is not met as evidenced by: Based on review of 2021, 2022, and 2023 peer review cases and interview with the histotechnician 3/12/24, the laboratory failed to evaluate the results of 7 of 22 peer review cases used to verify the accuracy of the Mohs dermatopathology cases at least twice a year. Findings: 1. Review of 2022 peer review records revealed results from 2 of 8 cases were not evaluated. The following cases were not evaluated to determine agreement and ensure no

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Survey - March 11, 2021

Survey Type: Standard

Survey Event ID: 80AS11

Deficiency Tags: D5215 D5215

Summary:

Summary Statement of Deficiencies D5215 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(b)(2) The laboratory must verify the accuracy of any analyte, specialty or subspecialty assigned a proficiency testing score that does not reflect laboratory test performance (that is, when the proficiency testing program does not obtain the agreement required for scoring as specified in subpart I of this part, or the laboratory receives a zero score for nonparticipation, or late return or results). This STANDARD is not met as evidenced by: Based on review of 2019 and 2020 WSLH (Wisconsin State Laboratory of Hygiene) proficiency testing records and interview with TP (testing personnel) 3/11/21, the laboratory failed to verify the accuracy of the ungraded DTM (dermatophyte test medium) fungal culture samples for 2 of 3 events in 2019 and 1 of 3 events in 2020. Findings: Review of 2019 and 2020 WSLH proficiency testing records revealed: 1. On the 2019 SPMicro - B1 test event, the laboratory failed to verify the accuracy of sample DM-1 which was ungraded. The expected result for sample DM-1 was positive, and the laboratory's response was negative. There was no documentation that the laboratory recognized the result was unacceptable and there was no

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Survey - March 21, 2019

Survey Type: Standard

Survey Event ID: DIM911

Deficiency Tags: D3037 D5217 D5417 D5819 D6092 D6094 D6177 D3037 D5217 D5417 D5819 D6092 D6094 D6177

Summary:

Summary Statement of Deficiencies D3037 RETENTION REQUIREMENTS CFR(s): 493.1105(a)(4) Proficiency testing records. Retain all proficiency testing records for at least 2 years. This STANDARD is not met as evidenced by: Based on review of 2017, 2018, and 2019 WSLH (Wisconsin State Laboratory of Hygiene) proficiency testing records and interview with TP (testing personnel) 3/21 /19, the laboratory failed to retain all proficiency testing records for at least two years. Findings: 1. The laboratory failed to retain attestation statements signed by the laboratory director and TP for the 2017 SP Micro B2 event, the 2018 SP Micro B2 event, and the 2018 SP Micro B3 event. 2. The laboratory failed to retain the report form used to record responses for the 2018 SP Micro B1, B2, and B3 events. 3. The laboratory failed to retain the graded results for the 2017 SP Micro B2 event and the 2018 SP Micro B3 event. During interview at approximately 10:45 a.m., TP #1 confirmed the records were not retained. D5217 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(c)(1) At least twice annually, the laboratory must verify the accuracy of any test or procedure it performs that is not included in subpart I of this part. This STANDARD is not met as evidenced by: Based on review of the laboratory's policies and procedures, review of 2017, 2018, and 2019 pathology verification records, and interview with TP (testing personnel) 3 /21/19, the laboratory failed to verify the accuracy of the Mohs histopathology and dermatopathology slides at least twice a year during 2017 and 2018. The laboratory's Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 4 -- "QUALITY ASSESSMENT PLAN" states "... 4. Proficiency Testing: Mohs lab will participate in the American Society for Mohs Surgery Proficiency Testing Program as needed for Maintenance of Fellow Membership. Records will be maintained in 'ASMS Proficiency' section of Procedure Manual. Histopathology lab will participate in a peer review of twelve cases per year, as well as, consultation/corroboration of dermatopathology with..." Review of 2017, 2018, and 2019 pathology verification records revealed: 1. The laboratory participated in a peer review for 1 case through ASMS (American Society for Mohs Surgery) during 2017 and submitted 12 dermatopathology cases for review by an outside laboratory in May 2017. 2. During 2018, the laboratory submitted 1 case to ASMS for peer review, but the case was unacceptable. There was no documentation of resubmission. During interview at approximately 1:35 p.m., TP #1 confirmed that the laboratory did not resubmit the 2018 peer review case. He stated they attended the ASMS annual meeting instead. He verified they had not performed any other activities to verify the accuracy of the Mohs histopathology and dermatopathology testing during 2017 and 2018. D5417 TEST SYSTEMS, EQUIPMENT, INSTRUMENTS, REAGENT CFR(s): 493.1252(d) Reagents, solutions, culture media, control materials, calibration materials, and other supplies must not be used when they have exceeded their expiration date, have deteriorated, or are of substandard quality. This STANDARD is not met as evidenced by: Based on observation and interview with TP (testing personnel) 3/21/19, the laboratory failed to discard supplies that exceeded their expiration dates. Findings: During a tour of the laboratory approximately 12:30 - 12:50 p.m., the surveyor observed the following expired supplies available for use: Mohs Laboratory 1. 1 partial bottle of Gill 2 Hematoxylin (lot #045416, expiration date 9/2017); 2. 1 partial bottle of Eosin - Y Alcoholic 0.25% (lot #046743, expiration date 6/2018); 3. 1 box of Polarstat Plus Frozen Embedding Medium (lot #044033, expiration date 2/2018); 4. 1 box of Dermatophyte Test Medium (lot #1803805, expiration date 2/7/2019). Dermpath Laboratory 1. 1 box of fungus control slides (lot #56547 H, expiration date 1/2019); 2. 3 cubes of 10% Neutral Buffered Formalin (lot #31377, expiration date 7 /2016). During interview at approximately 1:50 p.m., TP #1 stated the formalin was there when he started but it had not been used. D5819 TEST REPORT CFR(s): 493.1291(j) All test reports or records of the information on the test reports must be maintained by the laboratory in a manner that permits ready identification and timely accessibility. This STANDARD is not met as evidenced by: Based on review of 2017, 2018, and 2019 DTM (dermatophyte test medium) fungal culture logs and interview with TP (testing personnel) 3/21/19, the laboratory failed to ensure that all DTM test reports were entered in the EMR (electronic medical records system) to ensure timely accesibility. Review of patient DTM fungal culture logs revealed that 19 patient DTM fungal cultures were performed from 12/1/17 - 2/18/19. During interview at approximately 12:05 p.m., TP #1 stated they recently realized that none of the DTM fungal culture results had been entered in patient charts (EMR) -- 2 of 4 -- since December 2017. He stated they are currently in the process of entering them in the EMR. D6092 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1445(e)(4)(iv) The laboratory director must ensure an approved

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