Providence Facey Medical Foundation-

CLIA Laboratory Citation Details

3
Total Citations
14
Total Deficiencyies
14
Unique D-Tags
CMS Certification Number 05D0558842
Address 11333 Sepulveda Blvd, Ste 100, Mission Hills, CA, 91345
City Mission Hills
State CA
Zip Code91345
Phone(818) 365-9531

Citation History (3 surveys)

Survey - July 15, 2025

Survey Type: Special

Survey Event ID: 4JWS11

Deficiency Tags: D0000 D2096 D6016 D2016 D6000

Summary:

Summary Statement of Deficiencies D0000 A proficiency testing desk review survey as performed on 07/15/2025, the laboratory was found not in compliance with the following CONDITION LEVEL DEFICIENCIES D2016 - 42 C.F.R. 493.803 Condition: Successful [proficiency testing] participation; and D6000 - 42 C.F.R. 493.1403 Condition: Laboratories performing moderate complexity testing; laboratory director. D2016 SUCCESSFUL PARTICIPATION CFR(s): 493.803(a)(b)(c) (a) Each laboratory performing nonwaived testing must successfully participate in a proficiency testing program approved by CMS, if applicable, as described in subpart I of this part for each specialty, subspecialty, and analyte or test in which the laboratory is certified under CLIA. (b) Except as specified in paragraph (c) of this section, if a laboratory fails to participate successfully in proficiency testing for a given specialty, subspecialty, analyte or test, as defined in this section, or fails to take remedial action when an individual fails gynecologic cytology, CMS imposes sanctions, as specified in subpart R of this part. (c) If a laboratory fails to perform successfully in a CMS- approved proficiency testing program, for the initial unsuccessful performance, CMS may direct the laboratory to undertake training of its personnel or to obtain technical assistance, or both, rather than imposing alternative or principle sanctions except when one or more of the following conditions exists: (1) There is immediate jeopardy to patient health and safety. (2) The laboratory fails to provide CMS or a CMS agent with satisfactory evidence that it has taken steps to correct the problem identified by the unsuccessful proficiency testing performance. (3) The laboratory has a poor compliance history. This CONDITION is not met as evidenced by: Based on review of the Certification and Survey Provider Enhanced Reporting (CASPER) - 0155D and American Proficiency Institute (API) records (202?-?, 202?- ?, and 202?-?), the laboratory failed to successfully participate in a proficiency testing 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 -- program approved by HHS for each specialty, subspecialty and analyte or test in which the laboratory is certified under CLIA, the laboratory failed to successfully participate in the analyte analyte name(s) resulting in unsuccessful performances. See D2118. D2096 ROUTINE CHEMISTRY CFR(s): 493.841(f) (f) Failure to achieve satisfactory performance for the same analyte or test in two consecutive testing events or two out of three consecutive testing events is unsuccessful performance. This STANDARD is not met as evidenced by: Based on review of the Certification and Survey Provider Enhanced Reporting (CASPER) Report 0155D Individual Laboratory Profile and API - American Proficiency Institute (API) report, the laboratory failed to achieve satisfactory performance for two of three consecutive events (2025-1 and 2025-2) for the analyte Potassium (specialty Routine Chemistry: The finding include: Potassium 60% - 2025 first testing event; Potassium 40% - 2025 second testing event. A review of the 2025 scores from American Proficiency Institute (API) confirmed the above findings. D6000 MODERATE COMPLEXITY LABORATORY DIRECTOR CFR(s): 493.1403 The laboratory must have a director who meets the qualification requirements of 493. 1405 of this subpart and provides overall management and direction in accordance with 493.1407 of this subpart. This CONDITION is not met as evidenced by: Based on a proficiency testing desk review of the CASPER 0155D report and (Proficiency Testing Programs) records for 2025-1 and 2025-2 events, the laboratory director failed to provide overall management and direction of the laboratory services. Refer to D6016. D6016 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1407(e)(4)(i) (e)(4)(i) The proficiency testing samples are tested as required under Subpart H of this part; This STANDARD is not met as evidenced by: Based on a proficiency testing desk review of the CASPER 0155D report and API records for 2025-1 and 2025-2 events, the laboratory director failed to ensure successful participation in an HHS proficiency testing program. Refer to D2096 analyte deficiency/deficiencies. See D2096. -- 2 of 2 --

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Survey - February 16, 2023

Survey Type: Standard

Survey Event ID: L8H411

Deficiency Tags: D6031 D5407

Summary:

Summary Statement of Deficiencies D5407 PROCEDURE MANUAL CFR(s): 493.1251(d) Procedures and changes in procedures must be approved, signed, and dated by the current laboratory director before use. This STANDARD is not met as evidenced by: Based on review of the laboratory's policies and procedures manual and interview with the testing personnel (TP); it was determined that the laboratory failed to update protocols in place and the effective date and signature of approval by the laboratory director. The findings included: 1. On the day of the survey February 16, 2023, at approximately 12:45 p.m. the procedure manual in place had not been reviewed, approved, signed, and dated by the laboratory director. 2. The TP affirmed on February 16, 2023, that the laboratory failed to update protocols for the current testing performed in the laboratory and that the effective date and the laboratory director's signature were missing. 4. The laboratory's testing declaration form stated that the laboratory processes approximately 8,157 patients test annually. D6031 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1407(e)(13) 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)(13) Ensure that an approved procedure manual is available to all personnel responsible for any aspect of the testing process; This STANDARD is not met as evidenced by: 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 -- Based on direct observation and interview with the laboratory testing personnel; it was determined that the laboratory director failed to ensure that a signed and dated approved written procedure manual is available at all times to all personnel responsible for any aspect of the testing process. See D5407. -- 2 of 2 --

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Survey - October 7, 2021

Survey Type: Standard

Survey Event ID: 01O811

Deficiency Tags: D5209 D5807 D6026 D2007 D5415 D6018 D6046

Summary:

Summary Statement of Deficiencies D2007 TESTING OF PROFICIENCY TESTING SAMPLES CFR(s): 493.801(b)(1) The samples must be examined or tested with the laboratory's regular patient workload by personnel who routinely perform the testing in the laboratory, using the laboratory's routine methods This STANDARD is not met as evidenced by: Based on surveyor's review of the American Proficiency Institute (API) proficiency testing records and interview with the testing personnel (TP) it was determined that the laboratory failed to ensure that the proficiency testing was performed with regular patient's samples workload by the laboratory personnel who routinely perform testing. Findings included: 1. Based on review of the laboratory's proficiency testing (PT) records, the PT samples testing had been performed by a laboratory staff who did not routinely performs laboratory testing instead of by the 15 testing personnel who routinely perform testing. 2. The TP affirmed on October 7, 2021 at approximately 12: 00 p.m., that the laboratory did not include proficiency testing samples in the regular patient workload during routine testing and that the testing was not performed by personnel who routinely perform the testing in the laboratory. 3. The laboratory testing declaration form signed by the laboratory director on 10/05/2021 indicates that the laboratory performed 6,663 tests annually. D5209 PERSONNEL COMPETENCY ASSESSMENT POLICIES CFR(s): 493.1235 As specified in the personnel requirements in subpart M, the laboratory must establish and follow written policies and procedures to assess employee and, if applicable, consultant competency. 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 -- This STANDARD is not met as evidenced by: Based on the lack of documentation, review of testing personnel competency assessment records, seven (7) randomly chosen patient records review, and interview with the testing personnel (TP) on October 7, 2021 as specified in the personnel requirements in subpart M, it was determined that the laboratory failed to establish and follow written policies and procedures to assess testing personnel competency. Findings include: 1. Based on review of the laboratory's policies and procedures, the laboratory failed to establish and follow written policies and procedures for competency assessment of the TP. 2. The laboratory listed in the CMS 209 Form 17 TP. 3. For 17 out of 17 TP from the laboratory personnel report Form CMS-209 and final test reports, the laboratory fail to provide documentation of training or competency assessment for the TP performing testing at the laboratory for the year 2020. 4. This deficient practice was affirmed by interview with the TP on October 7,2021 at approximately 1:00 p.m. D5415 TEST SYSTEMS, EQUIPMENT, INSTRUMENTS, REAGENT CFR(s): 493.1252(c) Reagents, solutions, culture media, control materials, calibration materials, and other supplies, as appropriate, must be labeled to indicate the following: (1) Identity and when significant, titer, strength or concentration. (2) Storage requirements. (3) Preparation and expiration dates. (4) Other pertinent information required for proper use. This STANDARD is not met as evidenced by: Based on observation of the laboratory's reagent materials and testing kits and interview with the laboratory's testing personnel (TP); it was determined that the laboratory failed to label reagents to indicate the opening, preparation, and expiration dates, when such reagents are used. The findings included: 1. Based on the surveyor's observation during the laboratory tour on October 7, 2021 at approximately 11:40 a. m., the TP indicated that no opening, preparation, or expiration date labels were documented as well as initials of the person preparing the reagents for all the reagents used in the laboratory. 2. The laboratory's TP affirmed in an interview conducted October 7, 2021 at approximately 12:00 p.m., that the reagents currently used to test patients samples were not labeled with opening, preparation, initials, and expiration dates. 3. Based on the laboratory's annual testing declaration submitted at the time of the survey, the laboratory analyzed approximately 19,364 samples annually. D5807 TEST REPORT CFR(s): 493.1291(d) Pertinent "reference intervals" or "normal" values, as determined by the laboratory performing the tests, must be available to the authorized person who ordered the tests and, if applicable, the individual responsible for using the test results. This STANDARD is not met as evidenced by: Based on interview with laboratory testing personnel (TP) and review of two (2) randomly chosen patients' reports; it was determined that the laboratory failed to inform the authorized providers of the tests interpretation for the presence or absence of SARS-CoV-2 (Covid19) when samples testing results were reported. The findings included: 1. For two (2) out of two (2) positive and negative testing results for -- 2 of 4 -- Covid19 reviewed on October 7, 2021 at approximately 12:30 p.m. the report submitted to the authorized providers showed no interpretation of the results. 2. The TP affirmed that no interpretation of the results was provided to the sample submitters for Covid-19 in the final reports. 3. The laboratory tests and reports an unknown number of samples for the presence or absence of Covid-19. D6018 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1407(e)(4)(iii) 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)(iii) Ensure that all proficiency testing reports received are reviewed by the appropriate staff to evaluate the laboratory's performance and to identify any problems that require

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