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 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
D6171 TESTING PERSONNEL QUALIFICATIONS
CFR(s): 493.1489(b)

(b) Meet one of the following requirements: (b)(1) Be a doctor of medicine, doctor of osteopathy, or doctor of podiatric medicine licensed to practice medicine, osteopathy, or podiatry in the State in which the laboratory is located; or (b)(2)(i) Have earned a doctoral, master's, or bachelor's degree in a chemical, biological, clinical or medical laboratory science, or medical technology from an accredited institution; or (b)(2)(ii) Be qualified under the requirements of § 493.1443(b)(3) or § 493.1449(c)(4) or (5); or (b)(3)(i) Have earned an associate degree in a laboratory science or medical laboratory technology from an accredited institution or— (b)(3)(ii) Have education and training equivalent to that specified in paragraph (b)(2)(i) of this section that includes— (b)(3)(ii)(A) At least 60 semester hours, or equivalent, from an accredited institution that, at a minimum, includes either— (b)(3)(ii)(A)(1) 24 semester hours of medical laboratory technology courses; or (b)(3)(ii)(A)(2) 24 semester hours of science courses that include— (b)(3)(ii)(A)(2)(i) 6 semester hours of chemistry; (b)(3)(ii)(A)(2)(ii) 6 semester hours of biology; and (b)(3)(ii)(A)(2)(iii) 12 semester hours of chemistry, biology, or medical laboratory technology in any combination; and (b)(3)(ii)(B) Have laboratory training that includes: (b)(3)(ii)(B)(1) Completion of a clinical laboratory training program approved or accredited by the ABHES or the CAAHEP (this training may be included in the 60 semester hours listed in paragraph (b)(3)(ii)(A) of this section); or (b)(3)(ii)(B)(2) At least 3 months documented laboratory training in each specialty in which the individual performs high complexity testing; or (b)(4) Successful completion of an official U.S. military medical laboratory procedures training course of at least 50 weeks duration and having held the military enlisted occupational specialty of Medical Laboratory Specialist (Laboratory Technician); or (b)(5) Notwithstanding any other provision of this section, an individual is considered qualified as a high complexity testing personnel under this section if they were qualified and serving as a high complexity testing personnel in a CLIA-certified laboratory as of December 28, 2024, and have done so continuously since December 28, 2024. (b)(6) For blood gas analysis— (b)(6)(i) Be qualified under paragraph (b)(1), (2), (3), (4), or (5) of this section; or (b)(6)(ii) Have earned a bachelor's degree in respiratory therapy or cardiovascular technology from an accredited institution; or (b)(6)(iii) Have earned an associate degree related to pulmonary function from an accredited institution. (b)(7) For histopathology, meet the qualifications of § 493.1449(b) or (f) to perform tissue examinations.


This STANDARD is not met as evidenced by:
Based on a review of personnel records, and an interview with the General Supervisor, the laboratory failed to ensure one of six Testing Personnel (TP) performing high complexity patient testing met the educational requirements as specified in the CLIA regulations. The findings include: 1. A review of the 2023-2025 personnel records revealed the educational degree presented for TP1 did not meet the requirements for TP performing high complexity testing in the Specialty of Blood Bank. 2. A further review of the transcript for TP1 revealed a degree in Human Resource Management which lacked the six Chemistry hours required as per §493.1489 (b)(2)(ii)(A)(2)(i) CLIA regulatory standard. 3. The Chief Operating Officer and the GS confirmed the above findings during the Day 2 exit conference on 10-08-2025 at 4:28 PM.