Summary:
Summary Statement of Deficiencies D5407 PROCEDURE MANUAL CFR(s): 493.1251(d) (d) Procedures and changes in procedures must be approved, signed, and dated by the current laboratory director before use. This STANDARD is not met as evidenced by: Based on review of laboratory procedures and interview with the laboratory manager, the laboratory failed to ensure the laboratory director (LD) approved and signed all laboratory procedures. Findings include: 1. Review of the laboratory procedures produced during the survey revealed that the LD had not approved or signed several of the procedures. 2. Interview with the laboratory manager at 1:45pm on 05/20/2026 confirmed the above findings. 3. The laboratory performs 18,710 total 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 --