Teton Dermatology, Llc Dba Epiphany Dermatology

CLIA Laboratory Citation Details

3
Total Citations
15
Total Deficiencyies
7
Unique D-Tags
CMS Certification Number 53D2009726
Address 984 W Broadway, Ste 4, Jackson, WY, 83001
City Jackson
State WY
Zip Code83001
Phone(307) 734-1800

Citation History (3 surveys)

Survey - April 26, 2022

Survey Type: Standard

Survey Event ID: 5Y5F11

Deficiency Tags: D5028 D5417 D5028 D5417

Summary:

Summary Statement of Deficiencies D5028 HISTOPATHOLOGY CFR(s): 493.1219 If the laboratory provides services in the subspecialty of Histopathology, the laboratory must meet the requirements specified in 493.1230 through 493.1256, 493. 1273, and 493.1281 through 493.1299. This CONDITION is not met as evidenced by: . Based on observation, review of the reagent log sheet, staff interview, and policy and procedure review, the laboratory failed to ensure staining reagents were not used beyond their expiration date for 1 of 2 procedures (Mohs surgery histopathology). Refer to D5417. . D5417 TEST SYSTEMS, EQUIPMENT, INSTRUMENTS, REAGENT CFR(s): 493.1252(d) Reagents, solutions, culture media, control materials, calibration materials, and other supplies must not be used when they have exceeded their expiration date, have deteriorated, or are of substandard quality. This STANDARD is not met as evidenced by: . Based on observation, review of the reagent log sheet, staff interview, and policy and procedure review, the laboratory failed to ensure staining reagents were not used beyond their expiration date for 1 of 2 procedures (Mohs surgery histopathology). The findings were: 1. Observation on 4/26/22 at 1 PM showed 1 container of 100% reagent alcohol, lot #1921402, had an expiration date of 2/6/22. 2. Review of the laboratory's 2022 reagent log sheet showed the 100% reagent alcohol, lot #1921402, was received and opened on 5/7/21 and had an expiration date of 9/20/23. 3. Interview with medical assistant (MA) #1 and MA #2 on 4/26/22 at 3:30 PM confirmed the 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 -- container of 100% reagent alcohol had expired, however they did not have an explanation as to the discrepancy with the log sheet. 4. Review of the Mohs surgery log sheet showed 41 Mohs surgeries had been performed since 2/6/22. 5. Review of the policy and procedure titled "Laboratory: Mohs surgery and Frozen Section, Quality Assessment; Environment, Instruments, Reagents, Materials and Supplies" effective January 2020 showed "... Supplies and Reagents...Expired reagents will be discarded in accordance with the manufacturer's instructions and all local, state, and Federal regulatory agencies." 6. Review of the policy and procedure titled "Laboratory: Mohs Surgery and Frozen Section, Hematoxylin & Eosin Staining Protocol" effective January 2020 showed "...Procedure: 1. Check the expiration dates of all reagents prior to use." THIS IS A REPEAT DEFICIENCY, last cited on 5/4/21. -- 2 of 2 --

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Survey - May 4, 2021

Survey Type: Standard

Survey Event ID: QEFP11

Deficiency Tags: D5209 D5217 D5417 D6029 D5217 D5417 D6029

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 review of the CMS-209 Laboratory Personnel Report, lack of documentation, and staff interview, the laboratory director failed to ensure the laboratory had a policy and procedure in place to ensure competency of testing personnel performing test procedures for 6 of 6 testing personnel (PA-C #1, PA-C #2, MD #1, MD #2, MD #3). The findings were: Review of the CMS-209 Laboratory Personnel Report dated 5/4/21 showed 6 employees were listed as testing personnel. Interview with the laboratory director on 5/4/21 at 4:45 PM revealed the laboratory did not have a policy and procedure in place to ensure testing personnel competency. D5217 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(c)(1) At least twice annually, the laboratory must verify the accuracy of any test or procedure it performs that is not included in subpart I of this part. This STANDARD is not met as evidenced by: Based on lack of documentation and staff interview, the laboratory failed to verify histopathology frozen section analysis test accuracy at least twice annually for 1 of 2 years (2020) of testing reviewed. In addition, the laboratory failed to verify the accuracy of KOH (potassium hydroxide) testing at least twice annually for 1 of 2 years (2019) of testing reviewed. The laboratory performed approximately 230 Mohs 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 -- surgery procedures in 2020 and approximately 40 KOH preps per year. The findings were: 1. Review of the laboratory case log showed a peer review of the histopathology frozen section analysis was performed on 8/13/20 for a sample collected on 3/27/20. There was no documentation the laboratory had verified the accuracy of the frozen section analysis a second time in 2020. Interview with the lab director on 5/4/21 at 4: 45 PM revealed he was aware of the required twice a year accuracy review, however had not implemented the review until recently. 2. Review of the laboratory's 2019 KOH testing log sheet and Quality Assessment KOH/Scabies Preps Peer Review log showed no evidence KOH testing had been verified for accuracy at least twice annually for 5 of 5 testing personnel. Interview with the laboratory director on 5/4/21 at 4:45 PM revealed the laboratory had performed the KOH accuracy evaluations, however they had not documented the results D5417 TEST SYSTEMS, EQUIPMENT, INSTRUMENTS, REAGENT CFR(s): 493.1252(d) Reagents, solutions, culture media, control materials, calibration materials, and other supplies must not be used when they have exceeded their expiration date, have deteriorated, or are of substandard quality. This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to ensure staining reagents were not used beyond their expiration date for 2 of 2 procedures (potassium hydroxide (KOH) and Mohs surgery histopathology). The findings were: 1. Observation on 5/4 /21 at 2 PM showed 1 container of Eosin Y Stain lot #1801907 had an expiration date of 1/26/2020; 1 container of Hematoxylin Stain lot #1801909 had an expiration date of 1/26/2020; and 1 bottle of Chlorazol Black E fungal stain had a lot # of 6259, an open date of 2/2016, and an expiration date of 9/15/18. 2. Review of the laboratory's billing log sheet from 6/2/19 through 5/4/21 showed the laboratory had performed 84 KOH procedures. 3. Review of the laboratory's case log from 1/26/20 through 5/4/21 showed the laboratory performed 22 Mohs surgery frozen sections. 4. Interview with the laboratory director on 5/4/21 at 4:45 PM revealed he was unaware the stains had expired. D6029 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1407(e)(11) The laboratory director is responsible for the overall operation and administration of the laboratory, including the employment of personnel who are competent to perform test procedures, and record and report test results promptly, accurate, and proficiently and for assuring compliance with the applicable regulations. (e) The laboratory director must-- (e)(11) Ensure that prior to testing patients' specimens, all personnel have the appropriate education and experience, receive the appropriate training for the type and complexity of the services offered, and have demonstrated that they can perform all testing operations reliably to provide and report accurate results. This STANDARD is not met as evidenced by: Based on review of the CMS-209 Laboratory Personnel Report, lack of documentation, and staff interview, the laboratory director failed to ensure the competency of personnel performing test procedures for 3 of 3 testing personnel (PA- C #1, PA-C #2, MD #1).The findings were: 1. Review of the CMS-209 Laboratory -- 2 of 3 -- Personnel Report showed 3 additional testing personnel were listed from the prior CLIA survey conducted on 8/22/18. Interview with the clinic manager on 5/4/21 at 4: 30 PM revealed PA-C #1 was hired in 2016; PA-C #2 was hired in April 2019; and MD #1 was hired in March 2019. 2. There was no documentation to show PA-C #1, PA-C #2, or MD #1 had been evaluated for competency prior to testing patient samples. 3. Interview with the laboratory director on 5/4/21 at 4:45 PM revealed he had educated, trained, and evaluated the testing personnel, however he had not documented the process. -- 3 of 3 --

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Survey - August 22, 2018

Survey Type: Standard

Survey Event ID: O2VS11

Deficiency Tags: D5433 D5607 D5433 D5607

Summary:

Summary Statement of Deficiencies D5433 MAINTENANCE AND FUNCTION CHECKS CFR(s): 493.1254(b)(1) For equipment, instruments, or test systems developed in-house, commercially available and modified by the laboratory, or maintenance and function check protocols are not provided by the manufacturer, the laboratory must establish a maintenance protocol that ensures equipment, instrument, and test system performance that is necessary for accurate and reliable test results and test result reporting. The laboratory must perform and document the maintenance activities specified in paragraph (b)(1)(i) of this section. This STANDARD is not met as evidenced by: Based on lack of documentation and interview with staff, the laboratory failed to develop and follow a function check protocol for laboratory microscopes used for histopathology and mycology testing for 2 years of testing reviewed from August 2016 to August 2018. The laboratory performed approximately 1700 histopathology tests and 15 to 20 mycology tests per year. Findings include: 1. The laboratory lacked documentation the microscopes used for potassium hydroxide (KOH) mycology tests and for histopathology permanently fixed slides and frozen section testing from Moh's surgery were maintained from August 2016 to August 2018. 2. In an interview with the laboratory manager on 08/22/2018 at approximately 3:15 P.M., staff stated the laboratory did not document microscope maintenance nor have a procedure stating the frequency maintenance was to be performed and documented. D5607 HISTOPATHOLOGY CFR(s): 493.1273(d)(f) (d) Tissue pathology reports must be signed by an individual qualified as specified in paragraph (b) or, as appropriate, paragraph (c) of this section. If a computer report is generated with an electronic signature, it must be authorized by the individual who 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 -- performed the examination and made the diagnosis. (f) The laboratory must document all control procedures performed, as specified in this section. This STANDARD is not met as evidenced by: Based on patient test records review and interview with staff, tissue test reports failed to include documentation of a signature, or computer generated electronic signature for 8 of 16 histopathology (dermatopathology) test reports reviewed for formalin fixed paraffin embedded tissue specimen reports reviewed for testing performed from August 2016 to August 2018. Findings include: 1. Test reports for histopathology biopsies ending in numbers (as recorded in the specimen log book) for specimens collected in 2016: #1389 and 1413, collected in 2017 for #451, 598, 1067 and for specimens collected in 2018 or #435, 271, and 1064 failed to include the signature of the qualified histopathology testing person. 2. Test reports reviewed were reports generated by laboratory personnel and added to the same test report received from the preparatory laboratory performing the gross analysis and did not include the signature of the person qualified to perform histopathology testing. 3. In an interview conducted on 08/22/2018 at approximately 3:00 P.M., staff confirmed histopathology reports failed to include the board certified dermatologist's signature or computer generated signature for the 8 histopathology reports performed by the laboratory. -- 2 of 2 --

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