Reliant Medical Group Neponset St Dermatology

Summary Statement of Deficiencies D0000 A CLIA recertification survey was conducted for the Reliant Medical Group Neponset St. Dermatology laboratory pursuant to the Clinical Laboratory Improvement Amendments (CLIA) of 1988 and CLIA regulations at 42 CFR 493. . 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 procedure manual review and interview, the laboratory director failed to approve, sign, and date laboratory procedures as evidenced by the following: * A new laboratory director was hired for the laboratory in February of 2023 according to the Supervisor of Ancillary Support interviewed on 8/22/23 at 9:45 AM. A review of the clinical laboratory procedure manual revealed that the current laboratory director had not reviewed and approved the laboratory policy and procedure manual. The laboratory performs approximately 80 Physician Performed Microscopy Procedures (PPMP) and 200 histopathology (MOHS slide exams) annually. 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 D0000 A CLIA recertification survey was conducted for the Reliant Medical Group Neponset St. Dermatology laboratory pursuant to the Clinical Laboratory Improvement Amendments (CLIA) of 1988 and CLIA regulations at 42 CFR 493. . D6084 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1445(e)(2) The laboratory director must ensure that the physical plant and environmental conditions provide a safe environment in which employees are protected from physical, chemical, and biological hazards. This STANDARD is not met as evidenced by: Based on observation, the laboratory director failed to provide a safe environment environment in which employees are protected from chemical and biological hazards as evidenced by the following: On the day of the survey in the presence of the laboratory director, it was observed that there was no permanently mounted eyewash which would provide fifteen minutes of continuously flowing water near the laboratory area. The laboratory director confirmed in an interview on 5/14/19 at 9:05 AM that there was no permanently mounted eyewash available in thelaboratory. 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 --