Ellsworth Municipal Hospital

Summary Statement of Deficiencies 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 coagulation reagent studies, observations of the ACL Top 350 coagulation analyzer, and confirmed by interview with General Supervisor #1 (GS #1) at 2:48 pm on 04/24/2026, the laboratory failed to meet the hematology (coagulation) requirements for test system/equipment/reagent verification as specified in the standard D5411. D5209 PERSONNEL COMPETENCY ASSESSMENT POLICIES CFR(s): 493.1235 As specified in the personnel requirements in subpart M, the laboratory must establish and follow written policies and procedures to assess employee and, if applicable, consultant competency. This STANDARD is not met as evidenced by: Based on review of the laboratory's policies and procedures, personnel records, and confirmed by interview with General Supervisor #1 (GS #1) at 8:30 am on 04/24 /2026, the laboratory failed to follow written policies and procedures for assessing competency for 3 out of 13 testing personnel (TP #7, TP #12, and TP #13) in 2024 and 2025. The findings include: 1. The laboratory's Ancillary Testing policy stated that the laboratory director will document training, authorization and annual competency evaluation for all personnel performing ancillary testing. 2. Review of Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 4 -- personnel records for TP #7, TP #12, and TP #13 did not include documentation of competency assessment performance for 2024 and 2025. 3. At the time of the survey, GS #1 confirmed the laboratory failed to assess and document annual competency for TP #7, TP #12, and TP #13 in 2024 and 2025. D5215 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(b)(2) The laboratory must verify the accuracy of any analyte, specialty or subspecialty assigned a proficiency testing score that does not reflect laboratory test performance (that is, when the proficiency testing program does not obtain the agreement required for scoring as specified in subpart I of this part, or the laboratory receives a zero score for nonparticipation, or late return or results). This STANDARD is not met as evidenced by: Based on review of American Proficiency Institute (API) proficiency testing (PT) records and confirmed by interview with General Supervisor #1 (GS #1) at 9:30 am on 04/24/2026, the laboratory failed to perform and document a self evaluation when the laboratory received 13 ungraded PT scores from three out of seven PT testing events from 01/01/2024- 04/24/2026. The findings include: 1. For 2025 testing event 2, the laboratory received ungraded PT test scores for the following: *2025 Chemistry Core- B-type natriuretic peptide (BNP) (specimen CM-07); total bilirubin (specimens CH-07, CH-09, and CH-10); and folate (specimens IA-07 and IA-09) *2025 Microbiology- mycoplasma pnemoniae (specimen MPM-04) 2. For 2025 testing event 3, the laboratory received ungraded PT test scores for the following: *2025 Chemistry Core- BNP (specimen CM-15) and total bilirubin (specimens CH-12 and CH-15) *2025 Hematology/Coagulation- blood cell identification (BCI-15) 3. For 2026 testing event 1, the laboratory received ungraded PT test scores for the following: *2026 Chemistry Core- total bilirubin (specimen CH-05) *2026 Microbiology- gram stain morphology (specimen GS-04) 4. At the time of the survey, GS #1 confirmed the laboratory failed to perform and document a self evaluation for the ungraded PT test scores listed above. D5221 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(d) All proficiency testing evaluation and verification activities must be documented. This STANDARD is not met as evidenced by: Based on review of American Proficiency Institute (API) proficiency testing (PT) records and confirmed by interview with General Supervisor #1 (GS #1) at 9:30 am on 04/24/2026, the laboratory failed to take and document

Summary Statement of Deficiencies D0000 A proficiency testing desk review survey was completed on August 7, 2025. The laboratory was found to be out of compliance with the following CONDITION LEVEL DEFICIENCIES: D2016 - 42 C.F.R 493.803 Condition: Successful Participation D6000 - 42 C.F.R 493.1403 Condition: Laboratory Director, Moderate Complexity 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 review of the Certification and Survey Provider Enhanced Reporting (CASPER) 155 report and graded results from the American Proficiency Institute (API), the laboratory failed to successfully participate in two consecutive testing 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 -- events for the analyte, digoxin. The laboratory had unsatisfactory scores for 2025 events 1 and 2. Refer to D2118. D2118 TOXICOLOGY CFR(s): 493.845(f) (f) Failure to achieve satisfactory performance for the same analyte or test in two consecutive testing events or two out of three consecutive testing events is unsuccessful performance. This STANDARD is not met as evidenced by: Based on review of the Certification and Survey Provider Enhanced Reporting (CASPER) 155 report and graded results from the American Proficiency Institute (API), the laboratory failed to achieve satisfactory performance (100% or greater) for two consecutive testing events for the analyte, digoxin. The findings include: 1. The laboratory received an unsatisfactory performance score of 60% for 2025 testing event 1 for the analyte, digoxin. 2. The laboratory received an unsatisfactory performance score of 20% for 2025 testing event 2 for the analyte, digoxin. 3. The CASPER 155 report and graded results from API confirm the findings listed above. D6000 MODERATE COMPLEXITY LABORATORY DIRECTOR CFR(s): 493.1403 The laboratory must have a director who meets the qualification requirements of 493. 1405 of this subpart and provides overall management and direction in accordance with 493.1407 of this subpart. This CONDITION is not met as evidenced by: Based on review of the Certification and Survey Provider Enhanced Reporting (CASPER) 155 report and graded results from the American Proficiency Institute (2025 events 1 and 2), the laboratory director failed to provide overall management and direction of the laboratory services. Refer to D6016. D6016 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1407(e)(4)(i) (e)(4)(i) The proficiency testing samples are tested as required under Subpart H of this part; This STANDARD is not met as evidenced by: Based on review of the Certification and Survey Provider Enhanced Reporting (CASPER) 155 report and graded results from the American Proficiency Institute (API), the laboratory director failed to ensure successful participation in an HHS approved proficiency testing program. Refer to D2118. -- 2 of 2 --

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 review of proficiency records and reports, the laboratory fails to successfully participate in a proficiency testing program for the analyte, automated white blood cell differential, for two consecutive testing events: 2020 third event and 2021 first event (refer to D2130). D2130 HEMATOLOGY CFR(s): 493.851(f) Failure to achieve satisfactory performance for the same analyte in two consecutive 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 -- events or two out of three consecutive testing events is unsuccessful performance. This STANDARD is not met as evidenced by: Based on review of proficiency testing reports and records, the laboratory failed to achieve satisfactory performance for the analyte, automated white blood cell differential for two consecutive testing events for unsuccessful participation. The laboratory received unsatisfactory scores of 28% for 2020 third testing event and 2021 first testing event. -- 2 of 2 --

Summary Statement of Deficiencies D5217 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(c)(1) At least twice annually, the laboratory must verify the accuracy of any test or procedure it performs that is not included in subpart I of this part. This STANDARD is not met as evidenced by: Based on review of proficiency testing records and confirmed by laboratory personnel identifier #1 (refer to the Laboratory Personnel Report) at approximately 11:00 am on 05/24/2018, the laboratory failed to verify the accuracy for direct antiglobulin testing (DAT) twice annually for four out of four time periods in 2016 and 2017. At the time of the survey, laboratory personnel identifier #1 confirmed that the laboratory had not verified the accuracy for DAT testing in 2016 and 2017. D5445 CONTROL PROCEDURES CFR(s): 493.1256(d)(1)(2)(g) Unless CMS Approves a procedure, specified in Appendix C of the State Operations Manual (CMS Pub. 7), that provides equivalent quality testing, the laboratory must-- (d)(1) Perform control procedures as defined in this section unless otherwise specified in the additional specialty and subspecialty requirements at 493.1261 through 493.1278. (d)(2) For each test system, perform control procedures using the number and frequency specified by the manufacturer or established by the laboratory when they meet or exceed the requirements in paragraph (d)(3) of this section. (g) The laboratory must document all control procedures performed. This STANDARD is not met as evidenced by: Based on lack of Individualized Quality Control Plan (IQCP) records, review of quality control (QC) records, and confirmed by laboratory personnel identifier #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 -- (refer to the Laboratory Personnel Report) at approximately 12:20 pm on 05/24/2018, the laboratory failed to perform a positive and negative control each day of patient testing for the Immunocard STAT Helicobacter pylori (H. pylori) test system. The findings include: 1. The laboratory performed controls with each new lot of tests for the H. pylori test system. 4. Laboratory personnel identifier #1 indicated that the laboratory intended to follow manufacturer's instructions for performing QC. 5. At the time of the survey, the laboratory did not have an IQCP for the Immunocard STAT H. pylori test system. -- 2 of 2 --