Well - just to follow up - we approached our Laboratory Compliance team to see what they knew and their response was. "we don't remember, but it was a "BIG DEAL". We then discussed with the Pathology Medical Director (he was the director when this happened) and he had some insight and suggested contacting the hospital's CLIA person (who was the same person who mad this "decision")
Our Path. Med. Dir. emailed them and - lo and behold - they were perfectly fine with it....... Needless to say, that email has been sent to compliance and is now added as an attachment in our QP manual so no one can dispute what we all think is correct!
Thanks for letting us know that we weren't crazy in our thought process!
