TJC for waived testing

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With the upcoming changes to CLIA regarding nursing no longer allowed to perform competency assessments for non-waived testing, we are looking to see how
we can streamline our POC processes.
We are looking to move waived testing from CAP (under our CLIA) to Joint Commission (TJC) under a nursing CLIA.  Currently at our site, waived testing falls under both TJC , since waived testing falls under TJC standards for hospitals, and CAP .  Duplicate work for us.
Nursing would then be more responsible/accountable for the waived testing they perform.  TJC doesn't require proficiency testing for waived testing- money savings.  We have never failed our waived testing proficiency testing under CAP.
Does anyone have this same process for waived testing and if so how is that working under nursing?
Thanks!
Deborah Martuch, MLS(ASCP), CPP
deborah.martuch@hf.org



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My organization has all waived POC testing under TJC. At our main hospital campus we have the waived and PPM testing occurring under its own CLIA. And our non-waived POC tests occur under the Clinical Laboratory's CLIA license which is CAP accredited. 
We also stopped doing proficiency testing for our waived tests under TJC for the money savings and POCC's time spent investigating failures/non-submits. All POCT (waived under TJC and non-wavied under CAP) is still overseen by our POC Department. We are the ones ultimately responsible for enforcing the regulations of both. 

We also have these split.  We actually have 3 separate CLIA certificates in our facility.  Our facility is TJC accredited and the lab is accredited by CAP.  The Lab CLIA certificate has the non-waived POC testing included, and is accredited/inspected by CAP.  We have a waived CLIA certificate for the waived POC testing done facility wide (glucometers, urine dipstick, urine preg, etc.) and nurse educators do the majority of the training/competency assessments.  Then we have a CLIA certificate for PPM that is for our birthing center since they are the only area doing PPM and the Laboratory director listed on the CLIA for PPM is the only one who can perform these competency assessments, we didn't feel as though this needed to be included with the other waived testing done facility wide, nor did we want it listed under CAP.  I still oversee all of these POC tests and ensure the proper regulations are met for each. 

I'm curious about regulatory guidance on "splitting" tests over multiple CLIA certificates for one site. We had some issues with TJC on that one. Does anyone have a regulatory reference on this topic?

Here at Methodist, the non-waived lab test is CAP and the waived testing (POC glucose and urine preg) are TJC. Nurse educators perform the training and competency on staff who operate the glucose meters and perform urine pregnancy tests. The Point of Care Coordinator oversee them as their technical supervisor. POCC perform competencies for staff operating non-waived point of care testing i.e. i-STAT used in the Cath Lab or respiratory department. 

UTMB has non-waived testing under CAP accreditation and waived testing under TJC.  We have Test Site Managers at each clinic or department.  They are trained annually by POCT.  They perform the waived testing competencies for their location.  The POCC perform most of the moderate complexity competencies and we also have a few nurses (BS and at least 2 years' experience) that also perform the competencies.

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