Summary:
Summary Statement of Deficiencies D2127 HEMATOLOGY CFR(s): 493.851(d) Failure to return proficiency testing results to the proficiency testing program within the time frame specified by the program is unsatisfactory performance and results in a score of 0 for the testing event. This STANDARD is not met as evidenced by: Based on a review of the American Academy of Family Physicians (AAFP) proficiency testing records and an interview with the Technical Consultant (TC), the laboratory failed to ensure Hematology results for one of three 2017 surveys were submitted within the time frame specified by the proficiency testing (PT) program. This affected one of six surveys reviewed. The findings include: 1. A review of the results from the 2017 Hematology survey Event-C revealed a score of 0 % (percent) due to a failure to receive results. 2. During an interview on 3/6/2018 at 11:23 AM, the TC stated and confirmed the Hematology survey for Event-C in 2017 was not performed before the cut off date, thus the results from the survey was not submitted within the timeframe specified by the PT program. D6017 LABORATORY DIRECTOR RESPONSIBILITIES CFR(s): 493.1407(e)(4)(ii) The laboratory director is responsible for the overall operation and administration of the laboratory, including the employment of personnel who are competent to perform test procedures, and record and report test results promptly, accurate, and proficiently and for assuring compliance with the applicable regulations. (e) The laboratory director must-- (e)(4)(ii) Ensure that results are returned within the timeframes established by the proficiency testing program. 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 -- This STANDARD is not met as evidenced by: Based on a review of the American Academy of Family Physicians (AAFP) proficiency testing records and an interview with the Technical Consultant (TC), the Laboratory Director failed to ensure Hematology results for one of three 2017 surveys were performed and submitted within the time frame specified by the proficiency testing (PT) program. This affected one of six surveys reviewed. The findings include: 1. Refer to D2127. Jeremy Westry, BS, MT (ASCP) Licensure and Certification Surveyor -- 2 of 2 --