Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 01D0027451 (X3) Date Survey Completed 09/13/2022
Name of Provider or Supplier Grove Hill Memorial Hospital Street Address, City, State 295 S Jackson St, Grove Hill, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies
D2173 COMPATIBILITY TESTING
CFR(s): 493.863(a)

Failure to attain an overall testing event score of at least 100 percent is unsatisfactory performance.


This STANDARD is not met as evidenced by:
Based on a review of the CMS (Centers for Medicare and Medicaid Services) CASPER reports and American Proficiency Institute (API) Proficiency Testing (PT) evaluations, the laboratory failed to satisfactorily perform in compatibility testing for two of three consecutive testing events, Event #3, 2021 and Event #2, 2022. These failures resulted in an initial unsuccessful participation for the laboratory. The findings include: 1. A review of the CASPER reports revealed the laboratory scored the following for compatibility testing: Event #3, 2021 80 % Event #2, 2022 80 % 2. A review of the API PT evaluations confirmed the above noted scores.