| 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 |
| D5211 | EVALUATION OF PROFICIENCY TESTING PERFORMANCE CFR(s): 493.1236(a) The laboratory must review and evaluate the results obtained on proficiency testing performed as specified in subpart H of this part. 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 Chief Operating Officer and the General Supervisor (GS), the laboratory failed to document review and evaluation of PT performance. This was noted for six of the 24 PT events reviewed. The findings include: 1. A review of the API PT records revealed no documentation of review of the returned evaluations by the Laboratory Director, or designee, for the following events: a) 2024 Hematology, 2nd Event. b) 2024 Microbiology, 2nd Event. c) 2024 Immunology and Immunohematology, 1st and 2nd Events. d) 2024 Chemistry Core, 1st and 3rd Events. 2. The Chief Operating Officer and the GS confirmed the above findings during the exit conference on 10-08-2025 at 4:28 PM. |