Summary:
Summary Statement of Deficiencies D0000 During a recertification survey on 10/02/2023, the laboratory was found out of compliance with the following conditions: 42 CFR 493.1215 Condition: Hematology 42 CFR 493.1409 Condition: Laboratories performing moderate complexity testing; technical consultant 42 CFR 493.1421 Condition: Laboratories performing moderate complexity testing: testing personnel D5024 HEMATOLOGY CFR(s): 493.1215 If the laboratory provides services in the specialty of Hematology, the laboratory must meet the requirements specified in 493.1230 through 493.1256, 493.1269, and 493. 1281 through 493.1299. This CONDITION is not met as evidenced by: Based on review of Department of Health and Human Services Centers for Medicare and Medicaid Services Laboratory Personnel Report (CLIA) for moderate and high complexity testing (Form CMS-209), laboratory policies, lack of policies and records, and quality control records, the laboratory failed to follow it's own policy for TP competency assessment (See D5209), failed to follow it's own policy for quality assessment (See D5291), and failed to have