Summary:
Summary Statement of Deficiencies D2016 SUCCESSFUL PARTICIPATION CFR(s): 493.803(a)(b)(c) (a) Each laboratory performing nonwaived testing must successfully participate in a proficiency testing program approved by CMS, if applicable, as described in subpart I of this part for each specialty, subspecialty, and analyte or test in which the laboratory is certified under CLIA. (b) Except as specified in paragraph (c) of this section, if a laboratory fails to participate successfully in proficiency testing for a given specialty, subspecialty, analyte or test, as defined in this section, or fails to take remedial action when an individual fails gynecologic cytology, CMS imposes sanctions, as specified in subpart R of this part. (c) If a laboratory fails to perform successfully in a CMS- approved proficiency testing program, for the initial unsuccessful performance, CMS may direct the laboratory to undertake training of its personnel or to obtain technical assistance, or both, rather than imposing alternative or principle sanctions except when one or more of the following conditions exists: (1) There is immediate jeopardy to patient health and safety. (2) The laboratory fails to provide CMS or a CMS agent with satisfactory evidence that it has taken steps to correct the problem identified by the unsuccessful proficiency testing performance. (3) The laboratory has a poor compliance history. This CONDITION is not met as evidenced by: Based on a review of CMS (Centers for Medicare and Medicaid) CASPER reports (#153 / #155) and a review of API (American Proficiency Institute) proficiency testing evaluations, the surveyor determined the laboratory failed to successfully participate in testing for the WBC (White Blood Cell Count - Hematology testing). The laboratory scored twenty percent (20 %) for the WBC count for Event #2 of 2019 and forty percent (40 %) for Event #1, 2020, failures of two of three consecutive testing events. These failures resulted in an initial unsuccessful proficiency testing participation. The findings include: 1. A review of the CASPER reports revealed the laboratory scored 20 % for the WBC count for Event #2, 2019 and 40 % for Event #1, 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 -- 2020. 2. A review of the API proficiency testing evaluations confirmed the above noted findings from the CASPER reports. D2130 HEMATOLOGY CFR(s): 493.851(f) Failure to achieve satisfactory performance for the same analyte in two consecutive events or two out of three consecutive testing events is unsuccessful performance. This STANDARD is not met as evidenced by: Based on a review of CMS (Centers for Medicare and Medicaid) CASPER reports (#153 / #155) and a review of API (American Proficiency Institute) proficiency testing evaluations, the surveyor determined the laboratory failed to satisfactorily perform in proficiency testing for the WBC (White Blood Cell Count - Hematology testing) for two of three consecutive testing events. The laboratory scored twenty percent (20 %) for the WBC count for Event #2 of 2019 and forty percent (40 %) for Event #1, 2020. These failures resulted in an initial unsuccessful proficiency testing participation. The findings include: 1. A review of the CASPER reports revealed the laboratory scored 20 % for the WBC count for Event #2, 2019 and 40 % for Event #1, 2020. 2. A review of the API proficiency testing evaluations confirmed the above noted findings from the -- 2 of 2 --