Summary:
Summary Statement of Deficiencies D0000 An announced CLIA validation survey was conducted at Pleasant Valley Hospital on February 11, 2020 by the West Virginia Office of Laboratory Services. The laboratory was surveyed under 42 CFR 493 CLIA Regulations. Specific deficiencies cited are as follows: D2087 ROUTINE CHEMISTRY CFR(s): 493.841(a) Failure to attain a score of at least 80 percent of acceptable responses for each analyte in each testing event is unsatisfactory analyte performance for the testing event. This STANDARD is not met as evidenced by: Based on a reivew of laboratory College of American Pathology (CAP) proficiency testing (PT) records and an interview with the general supervisor of the Chemistry department (GS3), the laboratory failed to attain a score of at least 80 percent for each analyte in the 2019 API 1st testing event for Routine Chemistry. Findings: 1. A review of the 2019 CAP 1st testing event PT records for Routine Chemistry identified an overall successful score of 98 percent for the testing event. 2. A review of the 2019 CAP 1st testing event PT records for Routine Chemistry identified an unsatisfactory analyte performance score of 60 percent for the analyte BUN. 3. A review of the 2019 CAP 1st testing event PT records revealed an investigation into the unsuccessful performance of the analyte BUN. The documented