Summary:
Summary Statement of Deficiencies D5805 TEST REPORT CFR(s): 493.1291(c) The test report must indicate the following: (c)(1) For positive patient identification, either the patient's name and identification number, or a unique patient identifier and identification number. (c)(2) The name and address of the laboratory location where the test was performed. (c)(3) The test report date. (c)(4) The test performed. (c)(5) Specimen source, when appropriate. (c)(6) The test result and, if applicable, the units of measurement or interpretation, or both. (c)(7) Any information regarding the condition and disposition of specimens that do not meet the laboratory's criteria for acceptability. This STANDARD is not met as evidenced by: Based on review of the laboratory's surgical pathology test reports and interview with the facility personnel, the pathology test report for one out of three patients failed to include the patient's name and identification number. Findings include: 1. The laboratory reads and interprets slides generated from dermatology biopsy specimens in the sub-specialty of histopathology with an approximate annual test volume of 375. 2. It is the practice of the laboratory to indicate the patient name and unique accession number on the Surgical Pathology Report. 3. One out of three patient test reports (patient J. R. on 12/12/17) reviewed during the survey failed to include the unique accession number, in addition to the patient name. 4. Review of the patient's slide from the testing date indicated above revealed the slide listed the accession number as "P17-2924 A1-1". 5. The facility personnel confirmed that the Surgical Pathology Report for the patient indicated above failed to include the unique accession number. 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 --