Wphpa Southern Westchester Family Medicine

CLIA Laboratory Citation Details

2
Total Citations
10
Total Deficiencyies
5
Unique D-Tags
CMS Certification Number 33D0141101
Address 2 Overhill Rd - Suite 225, Scarsdale, NY, 10583
City Scarsdale
State NY
Zip Code10583
Phone(914) 636-0077

Citation History (2 surveys)

Survey - August 14, 2023

Survey Type: Special

Survey Event ID: LDHK11

Deficiency Tags: D2000 D6015 D2000 D6015

Summary:

Summary Statement of Deficiencies D2000 ENROLLMENT AND TESTING OF SAMPLES CFR(s): 493.801 Each laboratory must enroll in a proficiency testing (PT) program that meets the criteria in subpart I of this part and is approved by HHS. The laboratory must enroll in an approved program or programs for each of the specialties and subspecialties for which it seeks certification. The laboratory must test the samples in the same manner as patients' specimens. For laboratories subject to 42 CFR part 493 published on March 14, 1990 (55 FR 9538) prior to September 1, 1992, the rules of this subpart are effective on September 1, 1992. For all other laboratories, the rules of this subpart are effective January 1, 1994. This CONDITION is not met as evidenced by: Based on a proficiency testing (PT) desk review of Center for Medicaid and Medicare Service (CMS) PT data reports, the laboratory failed to enroll in an approved PT program for the specialty Hematology in the calendar year 2023. Refer to D6015 D6015 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1407(e)(4) 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)(4) Ensure that the laboratory is enrolled in an HHS approved proficiency testing program for the testing performed. This STANDARD is not met as evidenced by: Based on a proficiency testing (PT) desk review of Center for Medicaid and Medicare 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 -- Service (CMS) PT data reports, the laboratory failed to enroll in an approved PT program for the specialty Hematology in the calendar year 2023. Refer to D2000 -- 2 of 2 --

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Survey - January 16, 2018

Survey Type: Standard

Survey Event ID: WCMR11

Deficiency Tags: D5403 D5791 D6021 D5403 D5791 D6021

Summary:

Summary Statement of Deficiencies D5403 PROCEDURE MANUAL CFR(s): 493.1251(b) The procedure manual must include the following when applicable to the test 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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