Summary:
Summary Statement of Deficiencies D3037 RETENTION REQUIREMENTS CFR(s): 493.1105(a)(4) (a)(4) Proficiency testing records. Retain all proficiency testing records for at least 2 years. This STANDARD is not met as evidenced by: Based on review of proficiency testing records and confirmed by laboratory director identifier #1 (LD#1) at 9:40 am on 7/13/2026, the laboratory failed to retain the proficiency testing attestation statements for four out of four proficiency testing events from 1/1/2025 - 7/13/2026. The findings include: 1. The laboratory did not have attestation statements for the following events: *2026 event 1 - microbiology and hematology/coagulation *2025 event 3 - microbiology *2025 event 2 - microbiology and hematology/coagulation *2025 event 1- microbiology 2. At the time of the survey, LD #1 confirmed the laboratory failed to retain to above attestation statements. D5215 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(b)(2) The laboratory must verify the accuracy of any analyte, specialty or subspecialty assigned a proficiency testing score that does not reflect laboratory test performance (that is, when the proficiency testing program does not obtain the agreement required for scoring as specified in subpart I of this part, or the laboratory receives a zero score for nonparticipation, or late return or results). This STANDARD is not met as evidenced by: Based on review of proficiency testing records and confirmed by interview with Laboratory Director identifier #1 (LD #1) at 9:40 am on 7/13/2026, the laboratory Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number (X3) Date Survey Completed Name of Provider or Supplier Street Address, City, State -- 1 of 3 -- failed to perform a self evaluation when the laboratory received an ungraded PT score from one out of four testing events from 01/01/2025- 7/13/2026. The findings include: 1. For 2026 event 1, the laboratory received an ungraded PT score for QIAstat Enterovirus specimen RSP-04. 2. At the time of the survey, LD #1 confirmed the laboratory did not perform a self evaluation for the ungraded PT test score listed above. D5221 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(d) All proficiency testing evaluation and verification activities must be documented. This STANDARD is not met as evidenced by: Based on review of proficiency testing (PT) records and confirmed by interview with Laboratory Director identifier #1 (LD #1) at 9:40 am on 7/13/2026, the laboratory failed to take and document