Summary:
Summary Statement of Deficiencies D5211 EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(a) The laboratory must review and evaluate the results obtained on proficiency testing performed as specified in subpart H of this part. This STANDARD is not met as evidenced by: Based on review of Proficiency Testing (PT) scores for 2018 and 2019 and interview with the laboratory personnel, the laboratory failed to provide a documented review of the PT results for the first event of 2018 and the first and second testing events of 2019 for the sub-specialty of routine chemistry. Findings include: 1. No documented reviews, including a written comment and signature, were presented during the survey to indicate that the laboratory director or designee reviewed the results for the testing events indicated above for blood gas testing. 2. There must be evidence of a review of the PT scores for each event even if the laboratory received a score of 100%. 3. There was no evidence of PT score summary sheets (provided by the PT organization) for testing events in 2018 and 2019. There were score summary sheets for the PT testing events that occurred in 2017. 4. The laboratory personnel acknowledged that there were no documented reviews of the PT scores for the events listed above. 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 --