Revere Health Eagle Mountain Fm/Urgent Care

Summary Statement of Deficiencies D6070 TESTING PERSONNEL RESPONSIBILITIES CFR(s): 493.1425(b)(1) Each individual performing moderate complexity testing must follow the laboratory's procedures for specimen handling and processing, test analyses, reporting and maintaining records of patient test results. This STANDARD is not met as evidenced by: Based on patient test record review and interview with the laboratory director /technical consultant, testing personnel are not following laboratory procedures for test reporting. Findings include: 1. Patient test report for 1074128 included an incorrect medical record number (MRN) on the instrument printout from the Complete Blood Count (CBC) analyzer. MRN on instrument printout was 104128, correct MRN was 1074128. 2. Patient test report for 1000059051 included a result of 95.0 for Mean Corpuscular Volume (MCV) on the instrument printout from the CBC analyzer. MCV result in patient chart was 95.1. 3. Standard Operating Procedure (SOP) for manual entry of test results includes instructions that a second review of manual entry be performed by a different testing personnel than the personnel performing the manual entry, and initials on the instrument printout from the CBC analyzer verifying that result entry was reviewed. 4. Instrument printouts from the CBC analyzer for both patients include initials indicating that second review was performed by a second testing personnel (Testing person 3). Errors in manual entry were not identified and corrected by this review. 5. In an interview on 6/28/21 at approximately 1:00 pm, the laboratory director/technical consultant confirmed that errors in manual data entry were not identified and corrected by second review. 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 D6054 TECHNICAL CONSULTANT RESPONSIBILITIES CFR(s): 493.1413(b)(9) The technical consultant is responsible for evaluating and documenting the performance of individuals responsible for moderate complexity testing at least annually, after the first year. This STANDARD is not met as evidenced by: Based on testing personnel competency evaluations review, lack of documentation, and interview with staff, the laboratory technical consultant failed to evaluate testing personnel competency at least annually for 1 of 2 years reviewed for 3 of 9 testing personnel, (B, H, and I) performing non-waived testing . Findings include: 1. Personnel competency records reviewed failed to include documentation of annual personnel Complete Blood Cell Count competency for 2018 for testing person B (from 04/10/2017 to 10/12/2018), and for testing persons H (last one recorded on 08 /15/2016) and I (last recorded 04/03/2016) for 2017. 2. In an interview conducted on 10/12/2018 at approximately 12:00 Noon, the director confirmed competency was missed for some testing personnel in 2017. 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 --