Grace Cottage Hospital

CLIA Laboratory Citation Details

4
Total Citations
10
Total Deficiencyies
6
Unique D-Tags
CMS Certification Number 47D0090944
Address 185 Grafton Rd, Townshend, VT, 05353
City Townshend
State VT
Zip Code05353
Phone(802) 365-7357

Citation History (4 surveys)

Survey - October 8, 2025

Survey Type: Standard

Survey Event ID: LC3611

Deficiency Tags: D5401 D5439 D5401 D5439

Summary:

Summary Statement of Deficiencies D5401 PROCEDURE MANUAL CFR(s): 493.1251(a) (a) A written procedures manual for all tests, assays, and examinations performed by the laboratory must be available to, and followed by, laboratory personnel. Textbooks may supplement but not replace the laboratory's written procedures for testing or examining specimens. This STANDARD is not met as evidenced by: Based on record review and staff interview, the laboratory (lab) personnel failed to follow the lab's D-Dimer quality control (QC) procedure for 2 out of 12 months reviewed in 2024 and 2025. Findings include: 1. Review on 10/8/2025 of the lab's D- Dimer individualized quality control plan (lab procedure reference 5.0111, last revised 4/28/2025) revealed instruction to perform QC testing using 2 levels of control material for each new lot and every 30 days. 2. Review on 10/8/2025 of D-Dimer control records from October 2024 through September 2025 revealed 30 day QC testing due in December 2024 and August 2025 had not been performed. QC had been performed for cartridge lot T14965 on 11/9/2024 and was due 12/9/2024 but no additional QC was performed for this lot number; QC was performed on a new lot, T15174, on 1/3/2025. QC was performed for cartridge lot T15689 on 7/29/2025 and was due 8/29/2025 but was not performed until 9/6/2025. 3. Review on 10/8/2025 of patient test records revealed 10 patient D-Dimer tests performed using cartridge lot T14965 had been reported between 12/9/2025 and 1/3/2025; and 4 patient D-Dimer tests performed using cartridge lot T15689 had been performed between 8/29/2025 and 9/6/2025. 4. Interview on 10/8/2025 at 11:30 a.m. with the Hematology Technical Supervisor confirmed the above findings and revealed the QC for D-Dimer testing had not been monitored to ensure QC was performed with the frequency instructed in the procedure. D5439 CALIBRATION AND CALIBRATION VERIFICATION 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 -- CFR(s): 493.1255(b) (b)(1) Following the manufacturer's calibration verification instructions; (b)(2) Using the criteria verified or established by the laboratory under 493.1253(b)(3)-- (b)(2)(i) Including the number, type, and concentration of the materials, as well as acceptable limits for calibration verification; and (b)(2)(ii) Including at least a minimal (or zero) value, a mid-point value, and a maximum value near the upper limit of the range to verify the laboratory's reportable range of test results for the test system; and (b)(3) At least once every 6 months and whenever any of the following occur: (b)(3)(i) A complete change of reagents for a procedure is introduced, unless the laboratory can demonstrate that changing reagent lot numbers does not affect the range used to report patient test results, and control values are not adversely affected by reagent lot number changes. (b)(3)(ii) There is major preventive maintenance or replacement of critical parts that may influence test performance. (b)(3)(iii) Control materials reflect an unusual trend or shift, or are outside of the laboratory's acceptable limits, and other means of assessing and correcting unacceptable control values fail to identify and correct the problem. (b)(3)(iv) The laboratory's established schedule for verifying the reportable range for patient test results requires more frequent calibration verification. This STANDARD is not met as evidenced by: Based on record review and staff interview, the laboratory (lab) failed to perform calibration verification using at least a minimal value near the lower limit of the lab's reportable range, a midpoint value, and a maximum value and every 6 months for Vitamin B12 and Vitamin D in 2025. Findings include: 1. Review on 10/7/2025 of calibration verification records for vitamin B12 and vitamin D revealed calibration verification performed failed to include 3 levels; 1 near the lower limit and 1 near the upper limit of the lab's reportable range and a 3rd level in-between. Calibration verification for vitamin B12 performed in January 2025 included 2 levels above the reportable range and 1 below the reportable range, no level in the middle. Calibration verification for vitamin B12 was performed again 10 months later in October 2025 and included only 1 level above and 1 level below the lab's reportable range, no third level was run in the middle of the range. Vitamin D's calibration verification in January 2025 included 5 samples but the lowest value (level 1) failed to meet acceptable criteria resulting in the lowest value verified well above the lab's lower limit of the reportable range; no follow up was conducted to address the failed performance for level 1. Calibration verification for vitamin D was performed again in June 2025; this included only 1 patient sample run as a blind sample with a reference lab. 2. Interview on 10/7/2025 at 1:15 p.m. with the Chemistry Technical Consultant confirmed the above findings and revealed the lab did not have acceptable criteria for performance using blind patient specimens. -- 2 of 2 --

πŸ”’ Unlock Deficiency Summary

Get full access to the detailed deficiency summary for this facility

One-time payment β€’ Lifetime access

Survey - November 16, 2023

Survey Type: Standard

Survey Event ID: 6GZ811

Deficiency Tags: D5400 D5555 D5400 D5555

Summary:

Summary Statement of Deficiencies D5400 ANALYTIC SYSTEMS CFR(s): 493.1250 Each laboratory that performs nonwaived testing must meet the applicable analytic systems requirements in 493.1251 through 493.1283, unless HHS approves a procedure, specified in Appendix C of the State Operations Manual (CMS Pub.7), that provides equivalent quality testing. The laboratory must monitor and evaluate the overall quality of the analytic systems and correct identified problems as specified in 493.1289 for each specialty and subspecialty of testing performed. This CONDITION is not met as evidenced by: Based on observations, record review, and staff interview, the laboratory failed to meet analytic systems requirements for Immunohematology in 2023. Refer to D5555. D5555 IMMUNOHEMATOLOGY CFR(s): 493.1271(c)(f) (c) Blood and blood products storage. Blood and Blood products must be stored under appropriate conditions that include an adequate temperature alarm system that is regularly inspected. (c)(1) An audible alarm system must monitor proper blood and blood product storage temperature over a 24-hour period. (c)(2) Inspections of the alarm system must be documented. (f) Documentation. The laboratory must document all control procedures performed, as specified in this section. This STANDARD is not met as evidenced by: Based on observation, record review, and staff interview the laboratory (lab) failed to ensure red blood products were stored with an adequate temperature alarm system in 2023. Findings include: 1. Review on 11/16/2023 of the lab's policy titled "Blood Bank: Protocol for the Blood Bank Alarm System" last revised 6/27/23 revealed the 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 -- blood bank refrigerator (BB Frig) will alarm when the temperature falls outside 1.5 - 5.5 degrees Celsius. 2. Observation on 11/16/2023 at 9:00 a.m. of the BB Frig revealed it is used to store red blood cell products and the switch was not turned to the on position for the audible alarm. Further observation during a test of the alarm system on 11/16/23 at 9:00 a.m. revealed no alarm was activated outside the lab after the simulated temperature rose above 5.5 degrees Celsius. Another temperature probe was selected for a simulated temperature alarm test at 9:05 a.m.; this probe is used for the hospital's electronic temperature recording system (Sensoscientific). 3. Review on 11/16/2023 of the Sensoscientific temperature log for the BB Frig revealed temperatures were recorded every 15 minutes. The temperature after the alarm test for the BB Frig was not recorded until 9:12 a.m. and displayed a warning and indication that the alarm was delayed for 10 minutes before initiating notification. Further review of this log revealed the temperature would not alarm unless the recorded temperature fell outside 1-6 degrees Celsius. With the temperature logged every 15 minutes and a 10 minute delay, blood products could be stored outside the acceptable temperature for 25 minutes before the alarm is activated and notification has taken place. 4. Observations on 11/16/2023 revealed notification by phone from the hospital registration desk was first received by the lab at 9:24 a.m. and a page for the temperature alarm was first received on the lab's pager at 9:54 a.m. 5. Review of alarm checks for the BB Frig revealed it was last checked and passed the check on 6 /21/2023. 6. Interview on 11/16/2023 at 11:30 a.m. with the General Supervisor confirmed the above findings. The GS revealed the lab was not aware the primary alarm bell was taken out of service during renovation after the last alarm check. -- 2 of 2 --

πŸ”’ Unlock Deficiency Summary

Get full access to the detailed deficiency summary for this facility

One-time payment β€’ Lifetime access

Survey - November 17, 2021

Survey Type: Standard

Survey Event ID: L07O11

Deficiency Tags: D6117

Summary:

Summary Statement of Deficiencies D6117 TECHNICAL SUPERVISOR RESPONSIBILITIES CFR(s): 493.1451(b)(4) The technical supervisor is responsible for establishing a quality control program appropriate for the testing performed and establishing the parameters for acceptable levels of analytic performance and ensuring that these levels are maintained throughout the entire testing process from the initial receipt of the specimen, through sample analysis and reporting of test results. This STANDARD is not met as evidenced by: Based on record review and staff interview, the Hematology Technical Supervisor (TS) failed to ensure the the quality control (QC) procedure included acceptable parameters for QC materials used for complete blood counts performed on the Sysmex XN 550 analyzer in 2021, 2020 and 2019. Findings include: 1. Review on 11 /17/2021 of the laboratory's (lab) procedure titled "Sysmex XN 550 Hematology Analyzer Quality Control," effective 4/10/2019, the lab's procedure failed to define what the acceptable ranges for the QC material are. 2. Interview with the TS on 8/17 /2021 at 11:00 a.m. confirmed the above finding. The TS revealed the lab establishes their own acceptable ranges over time, but will use the manufacturer's ranges if an outlier occurs. 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 --

πŸ”’ Unlock Deficiency Summary

Get full access to the detailed deficiency summary for this facility

One-time payment β€’ Lifetime access

Survey - January 16, 2018

Survey Type: Standard

Survey Event ID: 5KW812

Deficiency Tags: D5449

Summary:

Summary Statement of Deficiencies No Tags No deficiency details available. 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 --

πŸ”’ Unlock Deficiency Summary

Get full access to the detailed deficiency summary for this facility

One-time payment β€’ Lifetime access