| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01D0027451 | (X3) Date Survey Completed 10/08/2025 |
| 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 |
| D2009 | TESTING OF PROFICIENCY TESTING SAMPLES CFR(s): 493.801(b)(1) (b)(1) The individual testing or examining the samples and the laboratory director must attest to the routine integration of the samples into the patient workload using the laboratory's routine methods. This STANDARD is not met as evidenced by: Based on a review of the 2024-2025 American Proficiency Institute (API) Proficiency Testing (PT) records and an interview with the General Supervisor (GS), the laboratory failed to ensure the Laboratory Director (or designee) signed the attestation statements for seven of the 24 PT events reviewed. The findings include: 1. A review of the 2024-2025 API PT records revealed the Laboratory Director (or designee) failed to sign the attestation statements for the following PT events: a) 2024 Chemistry Core - 1st and 3rd Events b) 2024 Chemistry Miscellaneous - 2nd Event c) 2024 Hematology/Coagulation - 3rd Event d) 2024 Microbiology - 2nd Event e) 2025 Hematology/Coagulation - 2nd Event f) 2025 Microbiology - 1st Event 2. The Chief Operating Officer and the GS confirmed the above findings during Day 2 exit conference on 10-08-2025 at 4:28 PM. |