Norton Children's Medical Group-Windy

CLIA Laboratory Citation Details

1
Total Citation
4
Total Deficiencyies
2
Unique D-Tags
CMS Certification Number 18D0321467
Address 4884 Brownsboro Rd, Louisville, KY, 40207-2342
City Louisville
State KY
Zip Code40207-2342
Phone502 896-4459
Lab DirectorMARIA BOWLING

Citation History (1 survey)

Survey - August 17, 2021

Survey Type: Standard

Survey Event ID: W6YS11

Deficiency Tags: D2128 D5413 D2128 D5413

Summary:

Summary Statement of Deficiencies D2128 HEMATOLOGY CFR(s): 493.851(e) (1) For any unsatisfactory analyte or test performance or testing event for reasons other than a failure to participate, the laboratory must undertake appropriate training and employ the technical assistance necessary to correct problems associated with a proficiency testing failure. (2) For any unacceptable analyte or testing event score, remedial action must be taken and documented, and the documentation must be maintained by the laboratory for two years from the date of participation in the proficiency testing event. This STANDARD is not met as evidenced by: Based on staff interview and record review of proficiency testing results from American Academy of Family Practice (AAFP) on 8/17/2021, the laboratory director failed to ensure proficiency test results were reviewed for one (1) out of one (1) event for 2019, and one (1) out of three (3) events for 2020. Findings include: 1. The laboratory scored a ninety-seven percent (97%) for AAFP Event C 2019 for Hematology. Record review revealed that the laboratory failed to document any

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