Skin And Cancer Associates Llp

CLIA Laboratory Citation Details

3
Total Citations
5
Total Deficiencyies
4
Unique D-Tags
CMS Certification Number 10D1094392
Address 17170 Royal Palm Blvd, Weston, FL, 33326
City Weston
State FL
Zip Code33326
Phone(954) 318-7335

Citation History (3 surveys)

Survey - April 14, 2021

Survey Type: Special

Survey Event ID: K1XV11

Deficiency Tags: D0000 D3000

Summary:

Summary Statement of Deficiencies D0000 A recertification survey was completed on 4/12/2021 to 4/14/2021 at Skin and Cancer Associates LLP. The laboratory was not in compliance with 42 CFR Part 493, Requirements for Laboratories. The following Condition was not met : 3000-Facility Administration D3000 FACILITY ADMINISTRATION CFR(s): 493.1100 Each laboratory that performs nonwaived testing must meet the applicable requirements under 493.1101 through 493.1105, unless HHS approves a procedure that provides equivalent quality testing as specified in Appendix C of the State Operations Manual (CMS Pub. 7). (a) Reporting of SARS-CoV-2 test results During the Public Health Emergency, as defined in 400.200 of this chapter, each laboratory that performs a test that is intended to detect SARS-CoV-2 or to diagnose a possible case of COVID-19 (hereinafter referred to as a "SARS-CoV-2 test") must report SARS-CoV-2 test results to the Secretary in such form and manner, and at such timing and frequency, as the Secretary may prescribe. This CONDITION is not met as evidenced by: Based on record review and interview, the laboratory failed to report 10 Coronavirus disease 2019 (COVID-19) negative results for BD Veritor System for Rapid Detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from 3/25/2021 to 4/8/2021. Findings Included: Review of Patient log revealed the laboratory started performing patient testing on 3/25/2021 with the BD Veritor System for Rapid Detection of SARS-CoV-2. The laboratory failed to report to the Florida Department of Health (FDOH) 10 negative COVID-19 results from 3/25/2021 to 4/8/2021. During an interview on 02/04/2021 at 1:30 pm, the laboratory director confirmed the laboratory failed to report to the FDOH 10 negative Covid-19 results from 3/25/2021 to 4/8/2021. 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 -- D5403 PROCEDURE MANUAL CFR(s): 493.1251(b) The procedure manual must include the following when applicable to the test procedure: (1) Requirements for patient preparation; specimen collection, labeling, storage, preservation, transportation, processing, and referral; and criteria for specimen acceptability and rejection as described in 493.1242. (2) Microscopic examination, including the detection of inadequately prepared slides. (3) Step-by-step performance of the procedure, including test calculations and interpretation of results. (4) Preparation of slides, solutions, calibrators, controls, reagents, stains, and other materials used in testing. (5) Calibration and calibration verification procedures. (6) The reportable range for test results for the test system as established or verified in 493.1253. (7) Control procedures. (8)

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Survey - April 14, 2021

Survey Type: Standard

Survey Event ID: FI1S11

Deficiency Tags: D5403 D0000

Summary:

Summary Statement of Deficiencies D0000 A recertification survey was completed on 4/12/2021 to 4/14/2021 at Skin and Cancer Associates LLP. The laboratory was not in compliance with 42 CFR Part 493, Requirements for Laboratories. The following Condition was not met : 3000-Facility Administration D3000 FACILITY ADMINISTRATION CFR(s): 493.1100 Each laboratory that performs nonwaived testing must meet the applicable requirements under 493.1101 through 493.1105, unless HHS approves a procedure that provides equivalent quality testing as specified in Appendix C of the State Operations Manual (CMS Pub. 7). (a) Reporting of SARS-CoV-2 test results During the Public Health Emergency, as defined in 400.200 of this chapter, each laboratory that performs a test that is intended to detect SARS-CoV-2 or to diagnose a possible case of COVID-19 (hereinafter referred to as a "SARS-CoV-2 test") must report SARS-CoV-2 test results to the Secretary in such form and manner, and at such timing and frequency, as the Secretary may prescribe. This CONDITION is not met as evidenced by: Based on record review and interview, the laboratory failed to report 10 Coronavirus disease 2019 (COVID-19) negative results for BD Veritor System for Rapid Detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from 3/25/2021 to 4/8/2021. Findings Included: Review of Patient log revealed the laboratory started performing patient testing on 3/25/2021 with the BD Veritor System for Rapid Detection of SARS-CoV-2. The laboratory failed to report to the Florida Department of Health (FDOH) 10 negative COVID-19 results from 3/25/2021 to 4/8/2021. During an interview on 02/04/2021 at 1:30 pm, the laboratory director confirmed the laboratory failed to report to the FDOH 10 negative Covid-19 results from 3/25/2021 to 4/8/2021. 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 -- D5403 PROCEDURE MANUAL CFR(s): 493.1251(b) The procedure manual must include the following when applicable to the test procedure: (1) Requirements for patient preparation; specimen collection, labeling, storage, preservation, transportation, processing, and referral; and criteria for specimen acceptability and rejection as described in 493.1242. (2) Microscopic examination, including the detection of inadequately prepared slides. (3) Step-by-step performance of the procedure, including test calculations and interpretation of results. (4) Preparation of slides, solutions, calibrators, controls, reagents, stains, and other materials used in testing. (5) Calibration and calibration verification procedures. (6) The reportable range for test results for the test system as established or verified in 493.1253. (7) Control procedures. (8)

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Survey - March 13, 2019

Survey Type: Standard

Survey Event ID: MDSY11

Deficiency Tags: D5609

Summary:

Summary Statement of Deficiencies D5609 HISTOPATHOLOGY CFR(s): 493.1273(e)(f) (e) The laboratory must use acceptable terminology of a recognized system of disease nomenclature in reporting results. (f) The laboratory must document all control procedures performed, as specified in this section. This STANDARD is not met as evidenced by: Based on record review and interview, the laboratory failed to provide complete histopathology quality control documentation from 3/13/17 to 3/13/19. Findings: Record review of quality control documentation showed there was no records of a reagent log with the lot numbers, expiration dates and open dates for the reagents used in their Hematoxylin & Eosin (H & E) stains. During an interview on 3/13/19 at 10:15 AM, the Risk Manager stated that he was unable to find a reagent log. 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 --

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