Southwest Michigan Dermatology

CLIA Laboratory Citation Details

3
Total Citations
14
Total Deficiencyies
8
Unique D-Tags
CMS Certification Number 23D0948005
Address 3000 Old Centre Road, Portage, MI, 49024
City Portage
State MI
Zip Code49024
Phone(269) 321-7546

Citation History (3 surveys)

Survey - February 12, 2024

Survey Type: Standard

Survey Event ID: H23B11

Deficiency Tags: D5401 D5403 D5403

Summary:

Summary Statement of Deficiencies D5401 PROCEDURE MANUAL CFR(s): 493.1251(a) A written procedures manual for all tests, assays, and examinations performed by the laboratory must be available to, and followed by, laboratory personnel. Textbooks may supplement but not replace the laboratory's written procedures for testing or examining specimens. This STANDARD is not met as evidenced by: . A. Based on record review and interview with the Mohs Technician, the laboratory failed to establish written procedures for its Scabies preparation testing for 2 (February 2022 to February 2024) of 2 years. Findings include: 1. A review of the laboratory's test menu revealed the laboratory performs Scabies preparation testing. 2. A review of the laboratory's test procedures revealed a lack of procedure to perform Scabies preparation testing. 3. An interview on 2/12/24 at 10:47 am with the Mohs Technician confirmed a procedure was not present. B. Based on observation, record review, and interview with the Mohs Technician, the laboratory failed to follow written procedures for its Tzank smear preparations for 2 (February 2022 to February 2024) of 2 years. Findings include: 1. The surveyor observed a "Tzanck Fungal Stain" bottle in the cabinet of the laboratory on 2/12/24 at 9:08 am. 2. A review of the laboratory's "Tzanck Prep" test procedure revealed a section stating, "The slide will then be taken to the lab for routine Hematoxylin and Eosin staining, and reviewed by the physician." 3. An interview on 2/12/24 at 10:50 am with the Mohs Technician confirmed the laboratory used the Tzanck Fungal Stain for its Tzanck smears and did not use routine Hematoxylin and Eosin staining according to the procedure. D5403 PROCEDURE MANUAL CFR(s): 493.1251(b) The procedure manual must include the following when applicable to the test 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 -- 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 - May 19, 2022

Survey Type: Standard

Survey Event ID: NNDU11

Deficiency Tags: D5787 D5801 D5801

Summary:

Summary Statement of Deficiencies D5787 TEST RECORDS CFR(s): 493.1283(a) The laboratory must maintain an information or record system that includes the following: (a)(1) The positive identification of the specimen. (a)(2) The date and time of specimen receipt into the laboratory. (a)(3) The condition and disposition of specimens that do not meet the laboratory's criteria for specimen acceptability. (a)(4) The records and dates of all specimen testing, including the identity of the personnel who performed the test(s). This STANDARD is not met as evidenced by: . Based on record review and interview with the Office Manager (OM) and the Mohs' Technician (MT), the laboratory failed to maintain a record system that included the identity of the surgeon performing the Mohs' surgery was not recorded on the Mohs' map for 1 ( 21-604) of 15 cases reviewed. Findings include: 1. A record review for 1 (21-604) of 15 Mohs' cases reviewed, the identity of the Mohs' surgeon was not recorded on the Mohs' map. 2. A interview on 5/19/2022 at 11:51, the OM and MT confirmed by a second look into the electronic medical records system for a signed copy of the final Mohs' map and it was not available. ***Repeat Deficiency from the 12/10/2020 survey *** D5801 TEST REPORT CFR(s): 493.1291(a) The laboratory must have an adequate manual or electronic system(s) in place to ensure test results and other patient-specific data are accurately and reliably sent from the point of data entry (whether interfaced or entered manually) to final report destination, in a timely manner. This includes the following: (a)(1) Results reported from calculated data. (a)(2) Results and patient-specific data electronically reported to network or interfaced systems. (a)(3) Manually transcribed or electronically 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 -- transmitted results and patient-specific information reported directly or upon receipt from outside referral laboratories, satellite or point-of-care testing locations. This STANDARD is not met as evidenced by: . Based on document review and interview with the Office Manager (OM) and the Mohs' Technician (MT), the laboratory failed to establish a system to ensure the transcribed Mohs' surgery site were accurately reported for 9 of 15 Mohs' cases reviewed. Findings include: 1. Record review revealed for 9 of 15 Mohs' cases, the surgical site on the pre-op biopsy report, the Mohs' map, and the Mohs' log did not match the location on the final report in the electronic medical record (EMR) system as follows: a. 21-152 performed on 2/22/2021 i. Pre-op biopsy report - left central forehead ii. Mohs' map and Mohs' log - left forehead iii. EMR report - left lateral forehead b. 21-219 performed on 3/10/2021 i. Pre-op biopsy report, Mohs' map, and Mohs' log - right ear ii. EMR report - right posterior ear c. 21-302 performed on 4/13 /2021 i. Pre-op biopsy report, Mohs' map, and the Mohs' log - left cheek ii. EMR report - left eyelid d. 21-379 performed on 5/05/2021 i. Pre-op biopsy report and Mohs' map - right central forehead ii. Mohs' log - right forehead iii. EMR report - right temple e. 21-703 performed on 8/17/2021 i. Per-op biopsy report and Mohs' map - right central temple ii. Mohs' log and EMR report - right temple f. 21-778 performed on 9/07/2021 i. Pre-op biopsy report, Mohs' map, and Mohs' log - epigastric skin ii. EMR report - chest g. 21-1231 performed on 12/29/2021 i. Pre-op biopsy report, Mohs' map, and Mohs' log - left lip ii. EMR report - left lower cutaneous lip h. 22-022 performed on 1/05/2022 i. Pre-op biopsy report - right superior central malar cheek ii. Mohs' map and Mohs' log - right malar cheek iii. EMR report - right superior medial malar cheek i. 22-479 performed on 5/04/2022 i. Pre-op biopsy report, Mohs' map, and Mohs' log - left inferior preauricular cheek ii. EMR report - left mid preauricular cheek 2. An interview on 5/19/2022 at 11:45 am, the OM and MT confirmed the locations on the pre-op biopsy report, Mohs' map, Mohs' log, and the final EMR report were not consistent with the original tumor site. -- 2 of 2 --

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Survey - March 22, 2018

Survey Type: Standard

Survey Event ID: HWJM11

Deficiency Tags: D5209 D5301 D5413 D5805 D5209 D5301 D5413 D5805

Summary:

Summary Statement of Deficiencies D5209 PERSONNEL COMPETENCY ASSESSMENT POLICIES CFR(s): 493.1235 As specified in the personnel requirements in subpart M, the laboratory must establish and follow written policies and procedures to assess employee and, if applicable, consultant competency. This STANDARD is not met as evidenced by: . Based on procedure review and interview, the laboratory Based on record review and interview, the laboratory failed to ensure written competency policies contained the six category requirements from subpart M and implemented bi-annually for four (#4, #5, #6, and #11) of four testing personnel performing the mycology and parasitology testing. Findings include: 1. On March 22, 2018 at 11:37 a.m., record review of the competency evaluations for four of four testing personnel revealed the policy did not contain the following six category requirements from subpart M: a. written competency policy did not contain the six requirements from subpart M 1. Direct observations of routine patient test performance, patient preparation, specimen handling, processing, and testing. 2. Monitoring the recording and reporting of patient test results. 3. Review of test results, worksheets, quality control records, proficiency testing results, and preventive maintenance. 4. Direct observation of performance of instrument maintenance and function checks. 5. Assessment of test performance through previously analyzed specimens, internal blind testing or proficiency testing samples. 6. Assessment of problem solving skills. 2. On March 22, 2018 at 11:37 a.m. when queried, processing personnel #7 as listed on the CMS-209 was not able to provide the surveyor with one of the two bi-annual evaluations in 2017 for four of four testing personnel performing the mycology and parasitology testing. 3. During the interview on March 22, 2018 at 11:37 a.m., processing personnel #7 confirmed the policy did not contain the six required categories and was not implemented bi- annually in 2017. ***Repeat Deficiency from the December 1, 2011 survey*** Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 3 -- D5301 TEST REQUEST CFR(s): 493.1241(a) The laboratory must have a written or electronic request for patient testing from an authorized person. This STANDARD is not met as evidenced by: . Based on record review and interview, the laboratory failed to have a electronic request for patient testing from an authorized person for the virology Tzanck smear for one of 18 patient charts audited. Findings include: 1. On March 22, 2018 at 12:08 p.m., record review for one (#12) of 18 patient charts audited revealed the laboratory did not have a electronic request for the virology Tzanck smear testing that was performed and written on the "Slide Log". 2. On March 22, 2018 at 12:08 p.m. when queried, processing personnel #7 as listed on the CMS-209 was unable to provide the surveyor documentation for a request in the patient's electronic medical records. 2. During the interview on March 22, 2018 at 12:08 p.m., processing personnel #7 confirmed the laboratory did not have an electronic request for the virology testing. D5413 TEST SYSTEMS, EQUIPMENT, INSTRUMENTS, REAGENT CFR(s): 493.1252(b) The laboratory must define criteria for those conditions that are essential for proper storage of reagents and specimens, accurate and reliable test system operation, and test result reporting. The criteria must be consistent with the manufacturer's instructions, if provided. These conditions must be monitored and documented and, if applicable, include the following: (1) Water quality. (2) Temperature. (3) Humidity. (4) Protection of equipment and instruments from fluctuations and interruptions in electrical current that adversely affect patient test results and test reports. This STANDARD is not met as evidenced by: . Based on observation,record review, and interview, the laboratory failed to monitor and document the humidity readings for 23 (April 2016 to March 2018) of 23 months of operation to ensure reliable histology instrument operation. Findings include: 1. On March 22, 2018 at 8:59 a.m., during a tour of the laboratory the surveyor observed the Leica CM 1510S Cryostat instrument in use. Review of the installation manual stated the "maximum relative humidity is less than 60%". 2. On March 22, 2018 at 8:59 a. m., record review revealed the laboratory was not able to provide documentation to show the relative humidity reading were monitored and documented for 23 of 23 months of operation. 3. During the interview on March 22, 2018 at 8:59 a.m., processing personnel #7 as listed on the CMS-209 confirmed the humidity readings were not monitored and documented. 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 -- 2 of 3 -- 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 record review and interview, the laboratory failed to include the test results for the virology Tzanck smear for one (#12) of 18 patient charts audited. Findings include: 1. On March 22, 2018 at 12:08 p.m., record review revealed for one of 18 patient charts audited the results for the virology Tzanck smear documented on the "Slide Log" was not included in the patient's electronic medical record (EMR). 2. During the interview on March 22, 2018 at 12:08 p.m., processing personnel #7 as listed on the CMS-209 confirmed the results were not in the patient's EMR records. -- 3 of 3 --

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