Sterling Urgent Care

CLIA Laboratory Citation Details

3
Total Citations
3
Total Deficiencyies
3
Unique D-Tags
CMS Certification Number 13D2184104
Address 7017 South Daisy Ln, Idaho Falls, ID, 83402
City Idaho Falls
State ID
Zip Code83402
Phone(208) 534-5878

Citation History (3 surveys)

Survey - September 10, 2024

Survey Type: Standard

Survey Event ID: B5SP11

Deficiency Tags: D5781

Summary:

Summary Statement of Deficiencies D5781

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Survey - July 12, 2022

Survey Type: Standard

Survey Event ID: QM5411

Deficiency Tags: D5311

Summary:

Summary Statement of Deficiencies D5311 SPECIMEN SUBMISSION, HANDLING, AND REFERRAL CFR(s): 493.1242(a) The laboratory must establish and follow written policies and procedures for each of the following, if applicable: (1) Patient preparation. (2) Specimen collection. (3) Specimen labeling, including patient name or unique patient identifier and, when appropriate, specimen source. (4) Specimen storage and preservation. (5) Conditions for specimen transportation. (6) Specimen processing. (7) Specimen acceptability and rejection. (8) Specimen referral. This STANDARD is not met as evidenced by: Based on a review of laboratory policies and procedures, a direct observation of patient samples and an interview with the laboratory manager on 7/12/2022 the laboratory failed to label two specimen blood tubes to include patient name or unique patient identification. The findings include: 1. The laboratory procedure, "Specimen Labeling and Transporting Procedure" established that specimens must be labeled with two patient identifiers and the collector must initial and put the date and time of collection on the patient specimen. 2. A direct observation during the laboratory tour identified one K2 EDTA specimen tube and one Lithium Heparin specimen tube on the tube rocker that were labeled with only the patient date of birth. 3. The laboratory failed to follow their policy and label the patient specimen blood tubes with two identifiers, collectors initials and date and time of collection. 4. An interview with the laboratory manager on 7/12/2022 at 2:50 pm confirmed that the laboratory failed to label specimens to ensure positive patient identification, following the laboratory procedure. 5. The laboratory reports performing 2300 tests annually. 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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Survey - February 25, 2021

Survey Type: Standard

Survey Event ID: JLC911

Deficiency Tags: D5429

Summary:

Summary Statement of Deficiencies D5429 MAINTENANCE AND FUNCTION CHECKS CFR(s): 493.1254(a)(1) For unmodified manufacturer's equipment, instruments, or test systems, the laboratory must perform and document maintenance as defined by the manufacturer and with at least the frequency specified by the manufacturer. This STANDARD is not met as evidenced by: Based on a record review of the Sysmex pocH-100i maintenance logs and an interview with the laboratory manager on 2/25/21, the laboratory failed to document maintenance as specified by the manufacturer. The findings include: 1. A record review of the maintenance logs for Sysmex pocH-100i, used for complete blood count (CBC) testing, identified that the laboratory failed to document bi-weekly maintenance in July 2020 through December 2020, January 2021 and February 2021. 2. An interview with the laboratory manager on 2/25/21 at 10:35 am confirmed that the laboratory has not documented bi-weekly maintenance on the Sysmex pocH-100i. 3. The laboratory reports performing 400 CBC tests annually. 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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