Summary:
Summary Statement of Deficiencies D2007 TESTING OF PROFICIENCY TESTING SAMPLES CFR(s): 493.801(b)(1) The samples must be examined or tested with the laboratory's regular patient workload by personnel who routinely perform the testing in the laboratory, using the laboratory's routine methods This STANDARD is not met as evidenced by: . Through a review of the form CMS-209 (Laboratory Personnel Report), the authorization page for blood gas testing, a review of proficiency test documentation for 2017 and 2018, as well as interviews with staff, it was determined proficiency testing samples were not tested by all personnel who routinely perform Blood Gas patient testing. Survey findings include: A. A review of the authorization page for blood gas testing revealed, testing personnel #1, #3, #4, #5, and #7 ( as listed on form CMS-209) were authorized by the Laboratory Director to perform Blood Gas testing. B. A review of 2017 and 2018 Proficiency testing attestation statements (six of six events) revealed all proficiency testing in 2017 and 2018 was performed by testing personnel #4 and #7. There was no documentation that testing personnel #1, #3, or #5 had performed proficiency testing an any event in 2017 or 2018. C. In an interview at 3:03 pm on 11/7/18 laboratory employee #4 (as listed on the CMS-209 (Laboratory Personnel Report) confirmed that laboratory testing personnel #1, #3, and #5 had not performed proficiency testing in the last two years. 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 --