Summary:
Summary Statement of Deficiencies 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 laboratory proficiency testing (PT) policy, laboratory proficiency testing (PT) record, and interview with the laboratory testing personnel (TP) #6, 5 of 6 laboratory TP who routinely test complete blood counts (CBC) failed to participate Hematology PT events in 2017. Findings include: 1. The laboratory PT policy states "All staff participates in proficiency testing." 2. The laboratory 2017 Hematology PT record shows only TP #6 (1 of 6) participated all 3 PT events. 3. In 2017, 6 laboratory TPs performed 282 CBC tests and reported these test results. 4. The TP #6 confirmed above findings on 04/10/2018 at 10:00 AM. 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 --