Summary:
Summary Statement of Deficiencies D3011 FACILITIES CFR(s): 493.1101(d) Safety procedures must be established, accessible, and observed to ensure protection from physical, chemical, biochemical, and electrical hazards, and biohazardous materials. This STANDARD is not met as evidenced by: Based on observation of the Mohs Laboratory and interview with laboratory personnel, the laboratory failed to have an accessible Eye Wash to ensure protection from chemical hazards. Findings include: a. The Eye Wash station was obstructed by a wall-mounted computer system and a cabinet on the floor, thus preventing quick access to use after a chemical splash to the eye(s). b. Laboratory personnel affirmed (4 /03/18) using chemicals and flammable solvents to stain Mohs slides for examination; and thus, the laboratory was required to have direct unobstructed access to the Eye Wash. c. The Safety of laboratory personnel could not be assured. Based on the Laboratory Personnel Report (LAB116), technicians are exposed to chemical hazards Monday through Thursday, staining approximately 4,000 slides minimum based on the reported estimated annual test volume of Mohs procedures. 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 --