Accrediting Agencies

Hi all, I am starting to see QC logs with an additional column to document that QC is acceptable to satisfy the CAP requirement below. I can see the usefulness of an additional QC acceptable column on logs in which staff record numbers, like ACT, that must be within a certain range. I see the extra column as a way to remind the user to go back and look at your results and do they fall within the acceptable range. Does anyone else do this? TIA POC.07540 QC Confirmation of Acceptability Phase II The results of controls are reviewed for acceptability before reporting results. NOTE: It is implicit in quality control that patient test results will not be re…

Hi all, How many patient comparison examples do you include for your semiannual comparison study?

Hi all, How are you complying to GEN.43825 Result Verification - Manual and automated result entries are verified before final acceptance and reporting by the computer. This verification is by the POC tester and not the POC Coordintor or other supervisor. The CAP inspector suggested a pop up box to prompt user to verify results before accuracy. Thanks in advance

I am in a small lab where we currently do blood gases on a RapidPoint. We will be bringing up one iStat in our ICU, and I'm confused about profiency testing. Per the 2015 CMS directive, we "are not permitted to test PT samples on multiple instruments unless that is how they routinely test patient specimens." In reading through CAP literature though, it is permitted to use two PT products that are totally different but test for the same analytes.---the example given is evaluating chemistries on a traditional analyzer and an iSTAT, since those results would not be comparable. So my confusion arises from the fact that I have two aqueous blood gas instruments. Do…

Hi all, Our respiratory department, that performs non waived testing, was cited by the state for not having the technical consultant assess competency. A respiratory therapist with an associate’s degree assessed competency. I have thought about modifying the lab director delegation form to include the respiratory therapist, however the respiratory therapist does not have the required educational background required by CLIA. I know our department is not the only one in this boat and was wondering how others have solved this problem. Thanks in advance, CAROL N

I'm currently working on corrective action for a missed ACT API survey. Does API normally send any sort of information with a failed PT as in, is a formal response required, when they recommend to cease testing, etc.? They scored 100% on both previous surveys for the year.

We are in our inspection window of opportunity for CAP. Would anyone using the Roche Inform II glucose monitor that has been inspected recently share their experience?