Gordon Memorial Hospital

CLIA Laboratory Citation Details

2
Total Citations
14
Total Deficiencyies
7
Unique D-Tags
CMS Certification Number 28D0697020
Address 300 East 8th Street, Gordon, NE, 69343
City Gordon
State NE
Zip Code69343
Phone(308) 282-0401

Citation History (2 surveys)

Survey - November 17, 2025

Survey Type: Special

Survey Event ID: JU6C11

Deficiency Tags: D0000 D2016 D2096 D6076 D6089 D0000 D2016 D2096 D6076 D6089

Summary:

Summary Statement of Deficiencies D0000 A proficiency testing desk review was completed on November 17, 2025. At the time of the review, the laboratory was not in compliance with the Clinical Laboratory Improvement Amendments of 1988, 42 CFR 493.1 through 42 CFR 493.1780. The following condition deficiencies were cited: D2016 - 42 C.F.R. 493.803 Condition: Successful participation [proficiency testing] D6076 - 42 C.F.R. 493.1441 Condition: Laboratories performing high complexity testing; laboratory director 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 desk review of proficiency testing (PT) records from the Certification and Survey Provider Enhanced Reporting (CASPER) 0155 report and American 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 -- Proficiency Institute (API) 2025 proficiency testing records, the laboratory did not successfully participate in a proficiency testing program approved by HHS, for each specialty, subspecialty, and analyte or test in which the laboratory is certified under CLIA. The laboratory failed to successfully participate in the specialty of Routine Chemistry for the analyte Iron, Total. Refer to D2096. D2096 ROUTINE CHEMISTRY CFR(s): 493.841(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 a proficiency testing desk review of CASPER 0155 report, American Proficiency Institute (API) proficiency testing 2025 event 2 and event 3 records, and an interview with the laboratory manager, the laboratory failed to achieve an overall satisfactory performance (80% or better) for the same analyte in two of three consecutive testing events in specialty of Routine Chemistry for the analyte Iron, Total. Findings are: 1. Review of the CASPER 0155 report revealed the following results: Iron, Total Event 2: The laboratory received an unsatisfactory score of 60%. Iron, Total Event 2: The laboratory received an unsatisfactory score of 40%. 2. A review of the API 2025 proficiency testing records confirmed the laboratory received the above results. 3. Phone interview with the laboratory manager on 11/17/2025 at 4: 15 PM confirmed the laboratory received the above results. D6076 LABORATORY DIRECTOR CFR(s): 493.1441 The laboratory must have a director who meets the qualification requirements of 493. 1443 of this subpart and provides overall management and direction in accordance with 493.1445 of this subpart. This CONDITION is not met as evidenced by: Based on a proficiency testing desk review of CASPER 0155 report and American Proficiency Institute 2025 event 2 and event 3 records, the laboratory director failed to manage successful proficiency testing participation. Refer to D6089. D6089 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1445(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 a proficiency testing desk review of CASPER 0155 report and American Proficiency Institute 2025 event 2 and event 3 records, the laboratory director failed to ensure successful participation in an HHS approved proficiency testing program. Refer to D2096. -- 2 of 2 --

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Survey - September 25, 2024

Survey Type: Standard

Survey Event ID: S6DW11

Deficiency Tags: D5421 D6151 D5421 D6151

Summary:

Summary Statement of Deficiencies D5421 ESTABLISHMENT AND VERIFICATION OF PERFORMANCE CFR(s): 493.1253(b)(1) Each laboratory that introduces an unmodified, FDA-cleared or approved test system must do the following before reporting patient test results: (1)(i) Demonstrate that it can obtain performance specifications comparable to those established by the manufacturer for the following performance characteristics: (1)(i)(A) Accuracy. (1)(i) (B) Precision. (1)(i)(C) Reportable range of test results for the test system. (1)(ii) Verify that the manufacturer's reference intervals (normal values) are appropriate for the laboratory's patient population. This STANDARD is not met as evidenced by: Based on surveyor review of list of tests performed, interview with the laboratory manager, and lack of documentation the laboratory failed to verify performance specifications on three out of three new moderate complexity test kits. 1. Review of the list of tests performed, presented by the laboratory, included three new moderate complexity test kits. The three new moderate complexity test kits include: Test kit #1 clostridium difficile Test kit #2 chlamydia trachomatis and neiserria gonorrhoeae Test kit #3 SARS-CoV-2, influenza A, influenza B, and respiratory syncytial virus 2. Interview with the laboratory manager on 9/25/2024 at 2:45 PM confirmed patient testing began in 2023 for test kit #1 clostridium difficile, test kit #2 chlamydia trachomatis and neisseria gonorrhoeae, and test kit #3 SARS-CoV-2, influenza A, influenza B, and respiratory syncytial virus. 3. Interview with the laboratory manager on 9/25/2024 at 2:54 PM confirmed the laboratory was unable to find the performance specifications for three out of three new moderate complexity test kits. 4. No documentation of verification of performance specifications was found during the survey. D6151 GENERAL SUPERVISOR RESPONSIBILITIES CFR(s): 493.1463(b)(3)(4) 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 -- (3) The director or technical supervisor may delegate to the general supervisor the responsiblity for providing orientation to all testing personnel; and (4) Annually evaluating and documenting the performance of all testing personnel. This STANDARD is not met as evidenced by: Based on review of testing personnel competency records and interview with the laboratory manager, the laboratory failed to ensure that 2023 competency evaluations were completed for three out of four testing personnel (Testing personnel #1, #2, and #4 as listed on the CMS-209 form). 1. Review of testing personnel competency records revealed no 2023 competency evaluations for three out of four testing personnel. 2. Interview with the laboratory manager on 9/25/2024 at 11:17 AM confirmed no 2023 competency evaluations were completed for three out of four testing personnel. -- 2 of 2 --

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