Saint Francis Medical Partners East, Llc

CLIA Laboratory Citation Details

1
Total Citation
3
Total Deficiencyies
3
Unique D-Tags
CMS Certification Number 44D0313875
Address 4066 Summer Avenue, Memphis, TN, 38122
City Memphis
State TN
Zip Code38122
Phone(901) 452-7391

Citation History (1 survey)

Survey - November 30, 2020

Survey Type: Standard

Survey Event ID: KYZ511

Deficiency Tags: D6029 D5413 D5291

Summary:

Summary Statement of Deficiencies D5291 GENERAL LABORATORY SYSTEMS QUALITY ASSESSMENT CFR(s): 493.1239(a) The laboratory must establish and follow written policies and procedures for an ongoing mechanism to monitor, assess, and, when indicated, correct problems identified in the general laboratory systems requirements specified at 493.1231 through 493.1236. This STANDARD is not met as evidenced by: Based on review of the laboratory's quality control (QC) and quality assessment records, and interview with the technical consultant, the laboratory failed to correct identified problems with QC lot management for six of nine QC lots reviewed in 2019 and 2020. The findings include: 1. Review of the laboratory's QC and quality assessment records revealed the following: Review done 8.7.19 for July 2019 QC records-noted problems with overlap in QC lots. No

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