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 eight of eight patient final test results, the Centers for Medicare and Medicaid Services (CMS)-116 form and interview with the technical consultant, the laboratory name and address were not correct on the final laboratory reports for 2017-2019. The findings include: 1) Review of 8 of 8 patients final test results dated 2 /10/17, 3/15/17, 8/24/17, 11/11/17, 2/10/18, 5/25/18, 10/12/18, and 1/5/19 revealed the name and address of the laboratory report missing for the patient's copy. 2) Review of the CMS -116 form revealed the laboratory name and address is St. Thomas Rutherford Hospital -Point of Care Testing, 1700 Medical Center Parkway, Murfreesboro, TN 37129. 3) Interview on January 22, 2019 at 1:00 p.m. with the technical consultant confirmed the name was incorrect and address incomplete on the laboratory final reports. 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 --