Waived Testing Site Inspections

 We have the big 3 inspect our POC program, CAP, TJC & CLIA. I downloaded the Point of Care requirements for each site and reviewed each test in our menu against these requirements. I find that it's not usually the test platform that is at issue, it's an employee performing the test incorrectly.

CMS website lists the CLIA requirements for COW labs.

• I have made sure each procedure follows manufacturers instructions.


• Initial competency assessments are performed and annual assessments are completed.


• I have a rounding schedule form for 10 offsites and 3 hospital sites that I go to each month. I address problems with the clinical leaders or office manager.


• If I find a repeated QC failures it is addressed with the clinical leader or office manager and employee. Retrain as warranted with clear expectations going forward.


• If repeated failures I bring this to the lab director and the employee goes through our hospitals remediation levels- verbal, written, coaching, dismissal.

I have yet to remove a test.  If test failures are occurring then I would look for a different methodology that might fit your specific needs better ie., simpler testing method, more rigorous training, etc. Good Luck