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Based upon observational tours and staff interviews, the laboratory staff failed to ensure preventive maintenance was performed for 2 of 4 randomly selected laboratory equipment.

The findings include:

Laboratory observational tours conducted 12/11/2014 from 0900 to 0940 revealed the following:

1. Glass pipette cleaner with a sticker that indicated the last PM (preventive maintenance) was 09/2013 and next PM was scheduled for 09/2014. Observation revealed no PM sticker that indicated preventive maintenance was performed on the glass pipette on 09/2014.

Interview with the Laboratory Manager conducted concurrently with tours on 12/11/2014 revealed the glass pipette cleaner was not PM on 09/2014 and no preventive maintenance log was available.

2. Blood/blood product freezer #2 with a sticker that indicated the last PM was 09/13 and the next PM was scheduled for 09/2014. Observation revealed no PM sticker that indicated preventive maintenance was performed on the blood/blood product freezer #2 on 09/2014.

Interview with the Laboratory Manager conducted concurrently with tours on 12/11/2014 revealed the blood/blood product freezer #2 was not PM on 09/2014 and no preventive maintenance log was available.

Based upon agreement review and staff interview, the hospital administration failed to ensure an agreement detailed the services provided for 1 of 2 reviewed agreements.

The findings include:

Review of the agreement between Hospital ABC and JKL Associates conducted 12/12/2014 1400 was related to patient privacy and confidentiality. Review of the agreement revealed no language that spoke to the laboratory services JKL Associates would provide to Hospital ABC.

Interview conducted 12/10/2014 at 1030 with the Laboratory Manager revealed when the laboratory runs out of supplies, JKL Associates run the laboratory test(s). Interview revealed the reason for the supply shortage was related to the Management Company financial restructure which started about two (2) years ago and as a result, suppliers request cash up front before supplies are shipped. Interview revealed laboratory supplies were maintained at PAR level (a minimum amount on hand) and monitored weekly and reported to the CEO (Chief Executive Officer) when supplies are low. Interview revealed laboratory supplies were available and a supply shipment was expected this week. Interview revealed JKL Associates last performed patient laboratory testing for Hospital ABC the week of 12/01/2014. Interview revealed the Laboratory Manager had no knowledge or documentation of JKL CLIA certificate.

Interview conducted 12/12/2014 at 1500 with the CEO (Chief Executive Officer) revealed the agreement between Hospital ABC and JKL Associates had no language that spoke to laboratory services.

NC00096486, NC00093533, NC00096486