Summary:
Summary Statement of Deficiencies D2100 ENDOCRINOLOGY CFR(s): 493.843(c) Failure to participate in a testing event is unsatisfactory performance and results in a score of 0 for the testing event. Consideration may be given to those laboratories failing to participate in a testing event only if-- (1) Patient testing was suspended during the time frame allotted for testing and reporting proficiency testing results; (2) The laboratory notifies the inspecting agency and the proficiency testing program within the time frame for submitting proficiency testing results of the suspension of patient testing and the circumstances associated with failure to perform tests on proficiency testing samples; and (3) The laboratory participated in the previous two proficiency testing events. This STANDARD is not met as evidenced by: Based on record review and staff interview the laboratory failed to participate in a proficiency testing (PT) event. Findings include: 1. Record review of the Casper 0155 D report on 1/16/19 revealed the lack of the PT score for 2018 event 1 for the subspecialty of Endocrinology. 2. Record review of the laboratory's PT records from College of American Pathologists for serum human chorionic gonadotropin (HCG) test on 1/16/19 revealed the laboratory failed to participate in PT for event 1 in 2018. The laboratory also failed to provide documentation for an alternate PT for HCG for that period. 3. Record review of the patient test log on 1/16/19 revealed HCG testing was performed for patients during the 2018 PT event 1 period. 4. Staff interview with the laboratory director on 1/16/19 at 11:45 AM confirmed the above findings. 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 --