Summary:
Summary Statement of Deficiencies D0000 An announced CLIA recertification survey was conducted at Chickahominy Family Physicians on February 20, 2019 by the Virginia Department of Health's Office of Licensure and Certification. The laboratory was surveyed under 42 CFR part 493 CLIA Requirements. Specific deficiency cited is as follows: D2007 TESTING OF PROFICIENCY TESTING SAMPLES CFR(s): 493.801(b)(1) The samples must be examined or tested with the laboratory's regular patient workload by personnel who routinely perform the testing in the laboratory, using the laboratory's routine methods This STANDARD is not met as evidenced by: Based on review of the Centers for Medicare and Medicaid Services Laboratory Personnel Report form (CMS 209), the laboratory's proficiency testing (PT) records and interviews, the laboratory failed to rotate PT among personnel performing Complete Blood Count (CBC) patient testing during the twenty-four (24) months reviewed. Findings include: 1. Review of the CMS Form 209 revealed ten (10) testing personnel. The office manager and primary testing personnel confirmed in an entrance interview that the listed TP performed patient CBC testing in calendar years 2017 and 2018. 2. Review of the laboratory's 2017 and 2018 American Proficiency Institute (API) PT documentation (a total of six events) revealed that testing personnel (TP) A performed three (3) of six (6) events reviewed. TP A signed attestations for completing the 2017 Event 1, 2017 Event 3, and 2018 Event 3. (See Personnel Code Sheet.) 3. In an exit interview with the office manager and primary testing personnel at approximately 1:00 PM, the above findings were confirmed. 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 --