Summary:
Summary Statement of Deficiencies D2122 HEMATOLOGY CFR(s): 493.851(b) Failure to attain an overall testing event score of at least 80 percent is unsatisfactory performance. This STANDARD is not met as evidenced by: Based on American Proficiency Institute (API ) proficiency testing record review for the last two of two years (2016 Hematology 1st, 2nd, and 3rd Event -2017 Hematology 1st, 2nd and 3rd Event) and interview with the Laboratory Director, the laboratory failed to achieve an 80% proficiency testing score for White Blood Differential, Granulocytes, and Lymphocytes plus Monocytes for the 2017 Hematology 2nd Event. Findings included: During API record review (2016 Hematology 1st, 2nd, and 3rd Event and 2017 Hematology 1st, 2nd, and 3rd Event ) it was found that the laboratory obtained a 0% proficiency testing score for White Blood Differential, Granulocytes, and Lymphocytes Plus Monocytes for the 2017 Hematology 2nd Event. No corrective documentation was present. During an interview at 12:00 PM on 04/03/18, the Laboratory Director stated the Testing Personnel had entered the whole number result instead of the percentage result. The Laboratory Director also stated they had reviewed the proficiency testing results with staff but did not implement and document